PNHP

“Mythbusters” by the Canadian Foundation for Healthcare Improvement

“Mythbusters” by the Canadian Foundation for Healthcare Improvement

The Canadian Foundation for Healthcare Improvement is dedicated to accelerating healthcare improvement and transformation for Canadians. We collaborate with governments, policy-makers, and health system leaders to convert evidence and innovative practices into actionable policies, programs, tools and leadership development. In this series of briefs, CFHI researchers refute many of the myths about the Canadian health system and publicly-financed health care in general. Especially recommended are:

To read more of CFHI’s Mythbusters,Ā visit their website.

Myths as Barriers to Health Care Reform

Dr. John P. Geyman, Professor Emeritus of Family Medicine at the University of Washington, served as PNHP’s President in 2005 and 2006. Dr. Geyman has written three books and contributed numerous academic papers on the failures of the U.S. health system and the need for single-payer national health insurance. In this article from the International Journal of Health Services, Dr. Geyman identifies and refutes six myths employed by the opponents of single-payer:

  1. The uninsured and underinsured get the care they need.
  2. The U.S. does not ration health care.
  3. The free market is the best way to resolve our health system problems.
  4. Incremental changes can solve our health system problems.
  5. The U.S. has the best health system in the world.
  6. National health insurance should not be given attention because it is politically unfeasible.

The references are also useful as a bibliography for those seeking evidence refuting these myths.

“Myths as Barriers to Health Care Reform in the United States”Ā (pdf)

Single-Payer FAQ

To view a two-page handout covering frequently asked questions about single-payer national health insurance,Ā click here.

What is single payer?

Single-payer national health insurance is a system in which a single public or quasi-public agency organizes health financing, but delivery of care remains largely private. Under a single-payer system, all Americans would be covered for all medically necessary services, including: doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs. Patients would regain free choice of doctor and hospital, and doctors would regain autonomy over patient care.

Is national health insurance ā€˜socialized medicineā€™?

No. Socialized medicine is a system in which doctors and hospitals work for and draw salaries from the government. Doctors in the Veterans Administration and the Armed Services are paid this way. The health systems in Great Britain and Spain are other examples. But in most European countries, Canada, Australia and Japan they have socialized health insurance, not socialized medicine. The government pays for care that is delivered in the private (mostly not-for-profit) sector. This is similar to how Medicare works in this country. Doctors are in private practice and are paid on a fee-for-service basis from government funds. The government does not own or manage medical practices or hospitals.

The term socialized medicine is often used to conjure up images of government bureaucratic interference in medical care. That does not describe what happens in countries with national health insurance where doctors and patients often have more clinical freedom than in theĀ U.S.,Ā where bureaucrats attempt to direct care.

Won’t single payer bankrupt the U.S.?

No, single payer will actually save money by slashing wasteful bureaucracy and adopting proven-effective cost controls like fee schedules, global budgets for hospitals, and negotiating drug prices with pharmaceutical companies. The savings – over $500 billion per year on overhead alone – are more than enough to cover all the uninsured. It turns out that it is much more expensive to keep patients away from health care in our current fragmented, market-based system than to provide care to all under an administratively simple single payer system.

Administrative overhead (also known as “transaction costs”) consumes one-third of current health spending in the U.S., a much higher share than in Canada or other nations. A recent paper on hospital administrative costs found that they consume 25 percent of the budgets of U.S. hospitals, compared to 12 percent in Canada and Scotland. Reducing hospital administrative costs to Canadian levels would save $150 billion a year alone.

Over the long-term, controlling the rise in health inflation saves even more money. Without reform, the U.S. is headed towards spending 20 percent of our GDP on health care within a decade (twice as much as other nations with universal coverage), even as we leave 27 million people uninsured and tens of millions more underinsured.

Wonā€™t this result in rationing like in Canada?

TheĀ U.S.Ā already rations care. Rationing inĀ U.S.Ā health care is based on income: if you can afford care, you get it; if you canā€™t, you donā€™t. A recent study found that 45,000 Americans die every year because they donā€™t have health insurance. Many more skip treatments that their insurance company refuses to cover. Thatā€™s rationing. Other countries do not ration in this way.

If there is this much rationing, why donā€™t we hear about it? And if other countries ration less, why do we hear about them? The answer is that their systems are publicly accountable, and ours is not. Problems with their health care systems are aired in public; ours are not. For example, in Canada, when waits for care emerged in the 1990s, Parliament hotly debated the causes and solutions. Most provinces have also established formal reporting systems on waiting lists, with wait times for each hospital posted on the Internet. This public attention has led to recent falls in waits there.

InĀ U.S.Ā health care, no one is ultimately accountable for how the system works. No one takes full responsibility. Rationing in our system is carried out covertly through financial pressure, forcing millions of individuals to forgo care or to be shunted away by caregivers from services they canā€™t pay for.

The rationing that takes place inĀ U.S.Ā health care is unnecessary. A number of studies (notably a General Accounting Office report in 1991 and a Congressional Budget Office report in 1993) show that there is more than enough money in our health care system to serve everyone if it were spent wisely. Administrative costs are at 31% ofĀ U.S.Ā health spending, far higher than in other countriesā€™ systems. These inflated costs are due to our failure to have a publicly financed, universal health care system. We spend about twice as much per person as Canada or most European nations, and still deny health care to many in need. A national health program could save enough on administration to assure access to care for all Americans, without rationing.

See also:Ā https://pnhp.org/news/2012/july/single-payer-does-not-equal-increased-wait-times

Who will run the health care system?

There is a myth that with national health insurance the government will make the medical decisions. But in a publicly financed, universal health care system, medical decisions are left to the patient and doctor, as they should be. This is true even in the countries like theĀ U.K.and Spain (or inĀ U.S.Ā systems like theĀ VA) that have socialized medicine.

In a public system, the public has a say in how itā€™s run. Cost containment measures are publicly managed at the state level by elected and appointed agencies that represent the public. This agency decides on the benefit package and negotiates doctor fees and hospital budgets. It also is responsible for health planning and the distribution of expensive technology. Thus, the total budget for health care is set through a public, democratic process. But clinical decisions remain a private matter between doctor and patient.

What about medical research?

Much current medical research is publicly financed through the National Institutes of Health. Under a universal health care system this would continue. For example, a great deal of basic drug research, for example, is funded by the government. Drug companies are invited in for the later stages of ā€œproduct development,ā€ the formulation and marketing of new drugs.Ā AZTĀ forĀ HIVĀ patients is one example. The early, expensive research was conducted with government money. After the drug was found to be effective, marketing rights went to the drug company.

Medical research does not disappear under universal health care system. Many famous discoveries have been made in countries with national health care systems. Laparoscopic gallbladder removal was pioneered in Canada. TheĀ CTĀ scan was invented in England. The treatment for juvenile diabetes by transplanting pancreatic cells was developed in Canada.

It is also important to note that studies show that, in theĀ U.S.,Ā the number of clinical research grants declines in areas of highĀ HMOĀ penetration. This suggests that managed care increasingly threatens clinical research. Another study surveyed medical school faculty and found that it was more difficult to do research in areas where highĀ HMOĀ penetration has enforced a more business-oriented approach to health care.

Finally, it appears that the increasing commercialization of research is beginning to slow innovation. Drug firmsā€™ increasing reliance on contract research organizations (and for-profit ethical-review boards) has coincided with a sharp drop in innovative new drugs and a spate of ā€œme-tooā€ drugs – minor variations on old drugs that offer little benefit other than extended patent life.

Wonā€™t this just be another bureaucracy?

The United States has the most bureaucratic health care system in the world. Over 31% of every health care dollar goes to paperwork, overhead,Ā CEOĀ salaries, profits, etc. Because theĀ U.S.Ā does not have a unified system that serves everyone, and instead has thousands of different insurance plans, each with its own marketing, paperwork, enrollment, premiums, and rules and regulations, our insurance system is both extremely complex and fragmented.

The Medicare program operates with just 3% overhead, compared to 15% to 25% overhead at a typicalĀ HMO.Ā Provincial single-payer plans in Canada have an overhead of about 1%.

It is not necessary to have a huge bureaucracy to decide who gets care and who doesnā€™t when everyone is covered and has the same comprehensive benefits. With a universal health care system we would be able to cut our bureaucratic burden in half and save over $300 billion annually.

How will we keep costs down if everyone has access to comprehensive health care?

People will seek care earlier when chronic diseases such as hypertension and diabetes are more treatable. We know that both the uninsured and many of those with skimpy private coverage delay care because they are afraid of health care bills. This will be eliminated under such a system. Undoubtedly the costs of taking care of the medical needs of people who are currently skimping on care will cost more money in the short run. However, all of these new costs to cover the uninsured and improve coverage for the insured will be fully offset by administrative savings.

In the long run, the best way to control costs is to improve health planning to assure appropriate investments in expensive, high-tech care, to negotiate fees and budgets with doctors, hospital and drug companies, and to set and enforce a generous but finite overall budget.

Will bundled payments and “paying for value” in health care reduce costs?

Bureaucrats at CMS are fixated on the meme that we can reduce spending by paying for the value of health care rather than the volume. They have been disappointed with models such as accountable care organizations, and they are now turning to MACRA and its alternative payment models (APMs), with a renewed surge of interest in bundled payments.

The concept behind bundled payments is that, by assigning a single fee to a given intervention such as a joint replacement, you will motivate physicians to not spend money on portions of the care that are not really necessary. Medicare, as the payer, gets the advantage of a discounted price, and the physicians and hospitals get to keep whatever they save beyond the discount.

Does this really reduce volume? The joint replacement will be done regardless, so what volume will be reduced? Doing only a cursory pre-op exam, missing the ejection murmur and omitting the pre-op cardiac consult? Send a patient home earlier when it is possible that the post-op status might not be fully stabilized? Cut back on rehabilitation, risking a less favorable long term outcome? These might reduce volume, but they certain bring into question quality and thus value.

Now they want to pay a set bundled payment for a heart attack. The clinical course of a heart attack is highly variable and could involve only a few or a great many interventions. Under a bundled payment, the physicians and hospital are bearing the risk of the high costs of a potentially complicated, protracted course. Isnā€™t it the role of the insurer, in this case Medicare, to pool risk? Shifting that risk to the health care delivery system creates the potential for either a reduction in important beneficial health care services, or exposing the delivery system to potential monetary losses and the risk of insolvency – neither of which are desirable.

Perhaps an even more important issue is the fallacy that you can bundle most care and thus make strides in bending the cost curve. Think of the Ā current proposals to bundle coronary artery bypass grafts and to bundle care for a heart attack – one might work some of the time, but the other has outcomes that are too variable. Now think of other hospital admissions – such as workup of a protracted fever, diagnosis and management of an HIV positive patient who has symptoms of a potentially serious but undiagnosed complication, or perhaps a child with fatigue and weight loss. The costs and outcomes are highly variable. How can you bundle those? Or think of the multitude of patients presenting in a ten minute office visit with a set of complex clinical symptoms that would require extensive workups. How do you bundle those?

To get to the goal of fifty percent of Medicare payments being tied to APMs, you are going to have to figure how how to bundle the large numbers of common clinical presentations, like the sore throat that turns out to be due to acute leukemia, or the routine family planning visit in a patient who feels ill that day and turns out to have diabetic ketoacidosis, or the chronic headache patient who has a focal motor seizure in front of you during the visit. What would otherwise be routine medical visits are often not bundable but are better handled on a fee-for-service basis. That makes the point that most health care is provided in a relatively fixed volume. It is really difficult to reduce the volume for patients who actually need care, and that’s almost all patients. Besides, in most instances we really donā€™t know how to measure value and convert that into a fixed fee. Volume is relatively fixed, and value is what we all strive for anyway.

Since itā€™s really cost that we are concerned about we should move forward with reform that has been proven repeatedly to slow the rate of health care inflation – a single payer national health program. Ā Politicians need to abandon their false meme that single payer is “not feasible.” What isn’t feasible is expecting to fix our dysfunctional health care financing system with “bundled payments.”

Answer contributed by Dr. Don McCanne, PNHP Senior Health Policy Fellow

How will we keep doctors from doing too many procedures?

This is a problem in any system that reimburses physicians on a fee-for-service basis. In todayā€™s health system, another problem is physicians doing too little for patients. So the real question is, ā€œHow do we discourage both overcare and undercare?ā€

One approach is to carefully control new capital expenditures. Once a hospital or imaging center purchases a multimillion-dollarĀ CTĀ scanner, it will try to generate enough scans to pay off the fixed cost. Explicit health planning should be done to assure that expensive machines and facilities are sited where they are needed and not where they are redundant and likely to generate overuse.

Another approach is to compare physiciansā€™ use of tests and procedures to their peers with similar patients. A physician who is ā€œoff the curveā€ will stand out. A related approach is to set spending targets for each specialty. This encourages doctors to be prudent stewards and to make sure their colleagues are as well, because any doctor doing unnecessary procedures will be taking money away from colleagues.

In addition, expert guidelines by groups like the American College of Physicians, etc., can help shape professional standards – which will certainly change over time as treatments change. This really gets to the heart of ā€œhow do you improve the quality of health care,ā€ which is a longer topic. Suffice it to say that single-payer, universal coverage provides a framework for achieving thoughtful quality improvement.

What will happen to physician incomes?

On the basis of the Canadian experience under national health insurance, we expect that average physician incomes should change little. However, the income disparity between specialties is likely to shrink.

The increase in patient visits when financial barriers fall under a single-payer system will be offset by resources freed up by a drastic reduction in administrative overhead and physiciansā€™ paperwork. Billing would involve imprinting the patientā€™s national health program card on a charge slip, checking a box to indicate the complexity of the procedure or service, and sending the slip (or a computer record) to the physician-payment board.

Under single payer, won’t physician incomes go down?

Not necessarily. Canadian physicians have done well under their single payer system – as documented in a recent,Ā careful study. In addition, streamlined billing under single payer would save US doctors vast amounts inĀ overhead, and free up additional physician time to see a few more patients. Hence, even if doctors’ gross incomes declined slightly (a questionable assumption if they’re freed up from insurance paperwork and able to devote more time to patient care) physicians’ average take home incomes wouldn’t change under single payer. Of course, some doctors’ incomes would go down – e.g. those who currently enjoy a particularly rich payer mix. On the other hand, some would see an increase – e.g. those currently caring for many Medicaid or uninsured patients.

– answer contributed by Dr. Steffie Woolhandler

How will we keep drug prices under control?

When all patients are under one system, the payer wields a lot of clout. TheĀ VAĀ gets a 40% discount on drugs because of its buying power. This ā€œmonopsonyā€ buying power is the main reason why other countriesā€™ drug prices are lower than ours. This also explains the drug industryā€™s staunch opposition to single-payer national health insurance.

Why shouldnā€™t we let people buy better health care if they can afford it?

Whenever we allow the wealthy to buy better care or jump the queue, health care for the rest of us suffers. If the wealthy are forced to rely on the same health system as the poor, they will use their political power to assure that the health system is well funded. Conversely, programs for the poor become poor programs. For instance, because Medicaid doesnā€™t serve the wealthy, the payment rates are low and many physicians refuse to see Medicaid patients. Calls to improve Medicaid fall on deaf ears because the beneficiaries are not considered politically important. Moreover, when the wealthy jump the queue, it results in longer waits for others. Studies in New Zealand and Canada show that the growth of private care in parallel to the public system results in lengthening waits. Additionally, allowing the development of a parallel, private system for the wealthy means the creation of a permanent lobby for underfunding public care. Such underfunding increases the demand for private care.

What will be covered?

All medically necessary care would be funded through the single payer, including doctor visits, hospital care, prescriptions, mental health services, nursing home care, rehab, home care, eye care and dental care. We also advocate a sharp increase in public health funding.

What about alternative care, will it be covered?

Alternative care that is proven in clinical trials to be effective will be covered. For example, spinal manipulation for some lower back conditions would be covered. Antioxidant vitamins would be covered for people with macular degeneration, but not for the general population (where they appear to be harmful). In general, coverage decisions will be made by the health care planning board or another public body. New kinds of treatments will be added to the benefits package over time as they are shown to be effective, including ā€œalternativeā€ treatments. Similarly, ineffective or harmful care can be removed from the benefits package, such as high dose epo for cancer.

Can a business keep private insurance if they choose?

Yes and no. Everyone has to be included in the new system for it to be able to control costs, reduce bureaucracy, and cover everyone. In Canada, businesses can purchase additional private insurance that covers things not covered by the national plan (e.g. private rooms, orthodontia, etc.). However, we support a comprehensive benefit package for the single-payer program that would eliminate the need (and most demand) for supplemental coverage.

Insurance companies would not be allowed to offer the same benefits as the universal health care system, a restriction contained in the traditional Medicare program. Allowing such duplication of coverage weakens and eventually destabilizes the health care system. It undermines the principle of pooling the risk. Health care systems act as universal insurers. At any one time the healthy help pay for those who are ill. If private insurers are allowed to cherry-pick the healthy, leaving the public health care system with the very sick, the system will fail.

This, in fact, is what we see happening to Medicare through the Medicare Advantage program. The government pays MedicareĀ HMOs 13% more than it pays traditional Medicare, yet theĀ HMOs care for a healthier mix of seniors. This is leading to privatization of Medicare and funding shortfalls for the traditional Medicare program.

What will happen to all of the people who work for insurance companies?

The new system will still need some people to administer claims. Administration will shrink, however, eliminating the need for many insurance workers, as well as administrative staff in hospitals, clinics and nursing homes. More health care providers, especially in the fields of long-term care, home health care, and public health, will be needed, and many insurance clerks can be retrained to enter these fields. Many people now working in the insurance industry are, in fact, already health professionals (e.g. nurses) who will be able to find work in the health care field again. But many insurance and health administrative workers will need a job retraining and placement program. We anticipate that such a program would cost about $20 billion, a small fraction of the administrative savings from the transition to national health insurance.

PNHPĀ has worked with labor unions and others to develop plans for a jobs conversion program with would protect the incomes of displaced clerical workers until they were retrained and transitioned to other jobs.

How will we contain costs with the population aging?

Studies show that aging of the population accounts for only a small fraction of the increases in health costs. Japan and Europe are already facing the problem of an aging population head-on and are doing fine. They have a much higher percentage of elderly than we do, and still spend far less on health care.

The best way to approach this is to regard it as a societal problem, one that needs a solution with everyone in mind. Germany and Japan recently adopted single-payer long-term care systems to cover the long-term care needs of the elderly at home and in specialized housing. Germany is pioneering a program that pays family members to care for the elderly at home.

What aboutĀ ERISA? Doesnā€™t it stand in the way of states implementing universal health care plans?

No.Ā ERISAĀ (the Employees Retirement Income Security Act) prevents a state from requiring that a self-insured employer provide certain benefits to their employees. However, a single-payer plan would not mandate the composition of employer benefit plans – it would replace them with a new system that would essentially be ā€œMedicare for all.ā€ The state would require employers to pay a payroll tax into the health care trust fund, which is clearly legal.

How will the Health Planning Board operate?

A health planning board would be a public body with representatives of patients and medical experts. The representatives would decide on what treatments, medications and services should be covered, based on community needs and medical science, and allocate capital for major new investments based on assessments of where need is greatest.

Since we could finance a fairly good system, like the Norwegian, Danish or Swedish system, with the public money we are already spending (60% of health costs), why do we need to raise the additional 40% (from employers and individuals)?

There are three reasons why theĀ U.S.Ā health care system costs more than other systems throughout the world. One, we spend two to three times as much as they do on administration. Two, we have much more excess capacity of expensive technology than they do (moreĀ CTĀ scanners,Ā MRIĀ scanners, and surgery suites). Three, we pay higher prices for services than they do.

There is no doubt that we do not need to spend more than we currently spend to cover comprehensive care for everyone. But the initial transition to a universal system would be very disruptive if we spent less. That is because we have a tremendous medical infrastructure, some of which would likely retain its excess capacity during the transition phase. Secondly, we would likely retain salaries for health professionals at their current levels. Thirdly, we would cover much more than most other countries do by including dental care, eye care, and prescriptions. And for these reasons we would need the extra 40% that we are already spending – butĀ NOTĀ more. We could cover all the uninsured and improve coverage for those who have skimpy coverage for the same amount we are currently spending!

How much of the health care dollar is publicly financed?

Over sixty percent (60.5 percent) of health spending in theĀ U.S.Ā is funded by government. Official figures for 2005 peg governmentā€™s share of total health expenditure at 45.4 percent, but this excludes two items:

1. Tax subsidies for private insurance, which cost the federal treasury $188.6 billion in 2004. These predominantly benefit wealthy taxpayers.

2. Government purchases of private health insurance for public employees such as police officers and teachers. Government paid private insurers $120.2 billion for such coverage in 2005: 24.7 percent of the total spending byĀ U.S.Ā employers for private insurance.

So, governmentā€™s true share amounted to 9.7 percent of gross domestic product in 2005, 60.5 percent of total health spending, or $4,048 per capita (out of total expenditure of $6,697).

By contrast, government health spending in Canada and theĀ U.K.Ā was 6.9 percent and 7.2 percent of gross domestic product respectively (or $2,337 and $2,371 per capita). Government health spending per capita in theĀ U.S.Ā exceeds total (public plus private) per capita health spending in every country except Norway, Switzerland and Luxembourg.

(Source: Himmelstein and Woolhandler, ā€œCompetition in a publicly funded healthcare systemā€ BMJ 2007; 335:1126-1129 [1 December] and Woolhandler and Himmelstein, Health Affairs, 2002, 21(4), 88, ā€œPaying for National Health Insurance – And Not Getting It.ā€

Why notĀ MSAs/HSAs?

Medical savings accounts (MSAs) and similar options such as health savings accounts (HSAs) are individual accounts from which medical expenses are paid. Once the account is depleted and a deductible is met, medical expenses are covered by a catastrophic plan, usually a managed care plan.

Individuals with significant health care needs would rapidly deplete their accounts and then be exposed to large out-of-pocket expenses; hence they would tend to select plans with more comprehensive coverage. Since only healthy individuals would be attracted to theĀ MSAs/HSAs, higher-cost individuals would be concentrated in the more comprehensive plans, driving up premiums and threatening affordability. By placing everyone in the same pool, the cost of high-risk individuals is diluted by the larger sector of relatively healthy individuals, keeping health insurance costs affordable for everyone.

Currently,Ā HSAs offer substantial tax savings to people in high-income brackets, but little to families with average incomes, and thus serve as a covert tax cut for the wealthy.

Moreover,Ā MSA/HSA plans discourage preventive care, which generally would be paid out-of-pocket, and do nothing to restrain spending for catastrophic care, which accounts for most health costs. Finally,Ā HSAs/MSAs discriminate against women, whose care costs, on average, $1,000 more than menā€™s annually. Hence, on theĀ MSA/HAS plan, the average woman pays $1,000 more out-of-pocket than her male counterpart.

Why not use tax subsidies to help the uninsured buy health insurance?

The major flaw of tax subsidies is that they would be used to help purchase plans in our current fragmented system. The administrative inefficiencies and inequities that characterize our system would be left in place, and we would continue to waste valuable resources that should be going to patient care instead. Moreover, even with tax subsidies, moderate- and lower-income individuals would be unable to afford good coverage, leaving them with modest benefits and high cost-sharing that would often make health care unaffordable. Instead of perpetuating our current inequities, tax policies should be used to create equity in contributions to a system in which everyone is assured access to comprehensive beneficial services.

If the tax subsidies are granted to individuals, employers would be motivated to drop their coverage, and most individuals covered would have merely rotated from employer coverage to individual coverage. The net reduction in the numbers of uninsured would be small. If the tax subsidies are granted to employers, a major shift in funding passes from employers to taxpayers without significant improvements efficiency or fairness. We can use the tax system to create equity in the way we fund health care, but we should also expect equity and efficiency in allocation of our health care resources. Distributing health resources according to human needs is possible only if we eliminate the private health plans and establish a publicly administered system.

What isĀ PNHPā€™s response to libertarian proposals for health savings accounts and deregulated insurance plans?

In response to the libertarian view: 1) We are already spending more than enough to provide all necessary health care services to everyone, and 2) The majority of Americans believe that everyone should be able to obtain necessary health care without having to face financial hardship.

The goal then is not only to have everyone covered with insurance, but also to make sure that insurance is effective in preventing the consequences of medical debt. We have a rapidly expanding epidemic of underinsurance, and the proposals of libertarians would expose the majority of us to the potential of excessive medical debt were we to develop significant medical problems. Policies with affordable premiums work for those who remain healthy, but most of health care spending is for those with major acute and chronic problems. The deregulated insurance plans andĀ HSAs proposed by libertarians cannot ever effectively address the problem of how we are going to pay for most of the health care in this nation.

The most efficient and effective system would be to establish a single risk pool covering everyone, and fund it equitably. The libertarians do have a problem with ā€œequitable.ā€ That would require a transfer from the healthy to those with greater health care needs. But the United States has an additional unique problem. Since we spend twice as much per capita as the average industrialized nation, each personā€™s share (national health expenditures divided by theĀ U.S.Ā population) is no longer affordable. For a family of four, that would be over $30,000 when median household income is about $50,000. So an equitably financed system in the United States would also require a transfer from wealthier individuals to the majority of us. Libertarians and egalitarians will never agree on the appropriate course. All other nations tend toward an egalitarian approach.

The World Health Report 2008, published by the World Health Organization, singles out the United States for its exceptionalism – a system with ā€œsingularly high additional private expenditureā€ that persistently underperforms ā€œacross domains of health outcomes, quality, access, efficiency and equity.ā€ Everyone should read this report. Very brief excerpts and a link to the full report can be found at:Ā https://pnhp.org/news/2008/october/the_world_health_rep.php

Wonā€™t competition be impeded by a universal health care system?

Advocates of the ā€œfree marketā€ approach to health care claim that competition will streamline the costs of health care and make it more efficient. What is overlooked is that past competitive activities in health care under a free market system have been wasteful and expensive, and are the major cause of rising costs.

There are two main areas where competition exists in health care: among the providers and among the payers. When, for example, hospitals compete they often duplicate expensive equipment in order to corner more of the market for lucrative procedure-oriented care. This drives up overall medical costs to pay for the equipment and encourages overtreatment. They also waste money on advertising and marketing. The preferred scenario has hospitals coordinating services and cooperating to meet the needs of their communities.

Competition among insurers (the payers) is not effective in containing costs either. Rather, it results in competitive practices such as avoiding the sick, cherry-picking, denial of payment for expensive procedures, etc. An insurance firm that engages in these practices may reduce its own outlays, but at the expense of other payers and patients.

Why not make people who are higher risk pay higher premiums?

Experience-rated insurance requires higher risk people to pay higher premiums. This approach says that people who have had cancer in the past, or who have chronic conditions like diabetes and hypertension, or who have had dangerous exposures to substances like asbestos, must pay more because they are at higher risk of using health services. Experience rating allows insurance companies to cherry-pick the healthiest people and either refuse to insure the sickest or, what amounts to the same thing, charge prohibitively high rates. This approach makes no sense. The whole point of insurance is to spread the risk so that everyone is covered. If you raise premiums – and thereby exclude from coverage – those people unfortunate enough to be sick, you defeat the point of both insurance and the health care system. Genetic conditions, childhood diseases, accidents, injuries and income distribution (or how much equality there is in a society) play a much bigger role in peopleā€™s health than ā€œindividual lifestyleā€ factors. And we know that even for motivated patients, alcohol and tobacco cessation are difficult, and medical weight loss nearly impossible. We need public health, primary care and education programs to try to prevent disease, but punishing patients once they are ill is inhumane and counterproductive.

Community-rated health insurance is the socially fair approach. It spreads the risks evenly among all the insured. It removes the punitive element. It does not discriminate against the very sick, nor against those of us who are at higher risk because of our age (say, over 50) or our gender (reproductive-age females have higher health expenses than men, for obvious reasons).

Health care should be organized as a public service, like a fire department. A health system organized as a business is discriminatory and accountable to no one. At some point in our lives all of us will predictably need health care. Hence health insurance is unlike any other form of insurance; we all are involved.

Wonā€™t this raise my taxes?

Currently, about 60% of our health care system is financed by public money: federal and state taxes, property taxes and tax subsidies. These funds pay for Medicare, Medicaid, theĀ VA,Ā coverage for public employees (including police and teachers), elected officials, military personnel, etc. There are also hefty tax subsidies to employers to help pay for their employeesā€™ health insurance. About 20% of health care is financed by all of us individually through out-of-pocket payments, such as co-pays, deductibles, the uninsured paying directly for care, people paying privately for premiums, etc. Private employers only pay 21% of health care costs. In all, it is a very ā€œregressiveā€ way to finance health care, in that the poor pay a much higher percentage of their income for health care than higher income individuals do.

A universal public system would be financed in the following way: The public funds already funneled to Medicare and Medicaid would be retained. The difference, or the gap between current public funding and what we would need for a universal health care system, would be financed by a payroll tax on employers (about 7%) and an income tax on individuals (about 2%). The payroll tax would replace all other employer expenses for employeesā€™ health care, which would be eliminated. The income tax would take the place of all current insurance premiums, co-pays, deductibles, and other out-of-pocket payments. For the vast majority of people, a 2% income tax is less than what they now pay for insurance premiums and out-of-pocket payments such as co-pays and deductibles, particularly if a family member has a serious illness. It is also a fair and sustainable contribution.

Currently, 47 million people have no insurance and hundreds of thousands of people with insurance are bankrupted when they have an accident or illness. Employers who currently offer no health insurance would pay more, but those who currently offer coverage would, on average, pay less. For most large employers, a payroll tax in the 7% range would mean they would pay slightly less than they currently do (about 8.5%). No employer, moreover, would gain a competitive advantage because he had scrimped on employee health benefits. And health insurance would disappear from the bargaining table between employers and employees.

Of course, the biggest change would be that everyone would have the same comprehensive health coverage, including all medical, hospital, eye care, dental care, long-term care, and mental health services. Currently, many people and businesses are paying huge premiums for insurance so full of gaps like co-payments, deductibles and uncovered services that it would be almost worthless if they were to have a serious illness.

Isnā€™t a payroll tax unfair to small businesses?

The payroll tax means a cost increase for businesses that are not currently insuring their workers. However, it is much less than they would pay at present for adequate coverage for themselves and their workers. For most small (and large) businesses already providing coverage, the payroll tax will mean substantial savings

Walter Reed Army Medical Center has been in the news lately for poor care and treatment of returning soldiers from Iraq. Wonā€™t national health insurance have similar problems?

As we consider what we can learn from the Walter Reed Army Medical Center debacle with regard to government-run efforts, some clarifications should be made:

1. Walter Reed Army Medical Center is an Army hospital and is run by the Department of Defense. TheĀ VAĀ hospitals are run by the Veterans Administration (Veterans Health Administration), a separate organization. The news media has clouded this fact and has led the public to presume that all government-run health efforts fail. TheĀ VAĀ health system continues to receive the best quality scores of any segment of theĀ U.S.Ā health system, with the most satisfied patients. It beats the bestĀ HMOs in quality ratings, has a model information system, and focuses on primary care. It has led in addressing medical errors and in its application ofĀ AHRQĀ quality guidelines to both inpatients and outpatients. In 2004 it won the Baldridge Prize for quality and patient-safety improvements.

2. There is a lot we can learn from the Walter Reed disgrace. Its operation was outsourced to a Halliburton-connected company in 2002, over the objections of some Army medical personnel and leadership, with a subsequent drastic reduction in staff and loss of government employees with institutional experience. There was also some hanky-panky with the contracting process; when the government employeesā€™ bid for the operations contract came in lower than the Halliburton companyā€™s bid, the bids were ā€œrecalculatedā€ to make the private company the lowest bidder.

(This section was contributed by Anne Carroll, MS, MPH.)

What about incremental reform of the health system?

As a matter of policy,Ā PNHPĀ expressly opposes many so-called gradual steps towards single-payer. Many well-meaning supporters often push these bills as ā€œfeasible stepsā€ to move us towards single-payer, but the history of these kinds of health reform efforts – Hawaii in 1974, Massachusetts in 1988, Oregon in 1989, Tennessee in 1992, Minnesota in 1992, Maine in 2003, etc. – shows that despite their claims of pragmatism, incremental reforms have consistently failed for more than three decades. Incremental reforms cannot garner administrative savings and redirect them to care. Hence they always founder on the shoals of cost. In addition, these reforms distract attention from the economically realistic, if politically challenging, option of single-payer reform.

What happens to investor-owned hospitals under national health insurance (NHI)?

ā€œTheĀ NHIĀ program would compensate owners of investor-owned hospitals, group/staff modelĀ HMOs, nursing homes and clinics for the loss of their clinical facilities, as well as any computers and administrative facilities needed to manageĀ NHI.Ā They would not be reimbursed for loss of business opportunities or for administrative capacity not used byĀ NHI.Ā Investor-owned providers would be converted to nonprofit status. TheĀ NHIĀ would issue long-term bonds to amortize the one-time costs of compensating investors for the appraised value of their facilities. These conversion costs would be offset by reductions in payments for capital that are currently folded into Medicare and other reimbursements.ā€ (Physiciansā€™ Proposal,Ā JAMA,Ā August 13, 2003.)

What proportion of health spending is for undocumented immigrants?

Very little. All foreign-born people, including immigrant workers who have legal status and who have lived in theĀ U.S.Ā for years, account for somewhat less than one-quarter of the uninsured, according to the Census Bureau. We do know that foreign-born people in theĀ U.S.are, on average, healthier and utilize little health care – about half of the health care (per capita) ofĀ U.S.-born persons. Surprisingly this is true whether or not they have insurance. Immigrant children receive very little care, 74 percent less overall than other children. So, if the foreign born are less than one-quarter of the uninsured, only one-eighth of health spending on the uninsured is going to the foreign born, which translates into a tiny fraction of allĀ U.S.Ā health spending. In fact, most immigrants have health insurance coverage, and 30% of immigrants use no health care at all in the course of a year. Undocumented immigrants are politically unpopular and hence a convenient target, but they are not the cause of rising health care costs.

The insurance industry says thatĀ PNHPā€™s figures on administrative costs are outdated. Is this true?

PNHPĀ has published a series of peer-reviewed studies over the past 20 years showing a steady increase in health administrative costs. While some aspects of administrative cost estimation (e.g. physiciansā€™ billing costs) require special studies, others, such as insurance overhead, can be easily tracked from publicly available data. These figures show no evidence of a fall in administrative costs since our most recent (2003) comprehensive estimate that administration consumes at least 31% ofĀ U.S.Ā health care spending.

Recently, right-wing ā€œthink tanksā€ have released studies claiming that Medicareā€™s administrative costs are far higher than the official 3% estimate. These estimates add to Medicareā€™s costs a share of the salaries of the President and members of Congress, the cost of running the Internal Revenue Service, etc. But none of these added costs would go away if Medicare were abolished, or up if Medicare were expanded to cover everyone. Most economists agree that such expenses should not be included in calculating Medicareā€™s overhead.

How much could the states save on administrative waste by adopting a statewide single-payer program?

Data on total health expenditures by state (excluding administrative spending) is available at:Ā http://www.cms.hhs.gov/NationalHealthExpendData/05_NationalHealthAccountsStateHealthAccountsResidence.asp#TopOfPage

Estimates of state administrative costs (a few years old, but the best available) are in an article by Drs. David Himmelstein and Steffie Woolhandler from 2003.

What will happen to malpractice costs under national health insurance?

They will fall dramatically, for several reasons. First, about half of all malpractice awards go to pay present and future medical costs (e.g. for infants born with serious disabilities). Single payer national health insurance will eliminate the need for these awards. Second, many claims arise from a lack of communication between doctor and patient (e.g. in the Emergency Department). Miscommunication/mistakes are heightened under the present system because physicians donā€™t have continuity with their patients (to know their prior medical history, establish therapeutic trust, etc) and patients arenā€™t allowed to choose and keep the doctors and other caregivers they know and trust (due to insurance arrangements). Single payer improves quality in many ways, but in particular by facilitating long-term, continuous relationships with caregivers. For details on how single payer can improve the quality of health care, see ā€œAĀ Better Quality Alternative: Single Payer National Health Insurance.ā€ For these and other reasons, malpractice costs in three nations with single payer are much lower than in the United States, and we would expect them to fall dramatically here. For details, see ā€œMedical Liability in Three Single-Payer Countriesā€ paper by Clara Felice and Litsa Lambkros.

ShouldĀ PNHPĀ support a public Medicare-like option in a market of private plans?

Response by Drs. David Himmelstein and Steffie Woolhandler:

The ā€œpublic plan optionā€ wonā€™t work to fix the health care system for 2 reasons.

1 – It foregoes at least 84% of the administrative savings available through single payer. The public plan option would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians offices, and nursing homes, which would still contend with multiple payers, and hence still need the complex cost tracking and billing apparatus that drives administrative costs. These unnecessary provider administrative costs account for the vast majority of bureaucratic waste. Hence, even 95% of Americans who are currently privately insured were to join the public plan (and it had overhead costs at current Medicare levels), the savings on insurance overhead would amount to only 16% of the roughly $400 billion annually achievable through single payer – not enough to make reform affordable.

2 – A quarter century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan – which started as the single payer for seniors and has now become a funding mechanism forĀ HMOs – and a place to dump the unprofitably ill. A public plan option does not lead toward single payer, but toward the segregation of patients; with profitable ones in private plans and unprofitable ones in the public plan.

Would a ā€œpublic plan optionā€ at least be a step in the right direction?

Answers contributed byĀ PNHPĀ Board members Dr. Andy Coates and Dr. Don McCanne

Answer by Dr. Andy Coates

I am not convinced that it is fair to call the ā€œpublic plan optionā€ (aka Jacob Hackerā€™s proposal) ā€œa move in the right direction.ā€

In the best case scenario this proposal would, I believe, accelerate the trend toward two-tiered care in our country. But we should recognize first that MoveOn and its friends are suggesting scenarios, not backing a specific proposal. The ā€œpublic plan option,ā€ as yet, amounts to no more than talking points, with some therefore ungrounded assertions along the lines of the quotes by Dr. Dean. (Single payer advocates in contrast have been winning support for legislation ā€”Ā H.R. 676Ā in the house and now a bill in the Senate, introduced by Senator Sanders.)

If these ā€œpublic plan optionā€ talking points are intended as a wedge for single payer against private insurance, we should see that they are also a wedge for private health insurance against single payer, the program of national health insurance that the large majority have been shown to want in poll after poll. Single payer has been dismissed by Dr. Dean and many other leading Democrats as ā€œnot politically feasible.ā€ Indeed, the ā€œpublic optionā€ notion grew out of this very idea ā€” the assumption that the insurance industry is too powerful, that we will always have private health insurance.

When Dean and others insist on the ā€œchoiceā€ of insurer, they insist upon the ā€œchoiceā€ of ā€œkeeping the insurance you haveā€ ā€” letā€™s keep the insurance business and its market, they assert. But the purpose of private health insurance and its market are the opposite of social responsibility ā€” and individual responsibility too.

Choice of insurance companies only matters because it restricts choice in care. What matters for our health is choice among caregivers, choice in location of care. The very purpose of the insurance market is to restrict these choices and by doing so extract money from the health care system. ā€œAdverse selection,ā€ the name of the game of health insurance business success is a reason why we should abolish health insurance as a business. Keeping that market offers the industry plenty of what Jessica calls ā€œprotection.ā€

The insurance companies know all about how to keep the healthy and wealthy while showing the sick and the poor the ā€œchoiceā€ of another plan. That is why the insurance industry lately has offered to move to community rating ā€” if only the government will criminalize the uninsured and mandate the purchase of health insurance.

Getting back to one of the scenarios ā€” the ā€œchoiceā€ of buying Medicare, the ā€œoptionā€ of paying health insurance premiums to a government entity (1) will not guarantee health care to all (as Dr. Dean asserts) and (2) will not be sustainable due to cost. Hundreds of billions of additional dollars annually will not be sustainable ā€” on top of 2.5 trillion dollars, on top of spending that is twice what any nation spends per person. That is why Mr. Obama called $600 billion over ten years a ā€œdown payment.ā€

In another scenario, Senator Baucus, leader of the bipartisan ā€œboard of directorsā€ who are working this out behind closed doors has suggested that the ā€œpublic optionā€ will be the chance to buy insurance through Federal Employee Health Benefit Program, something candidates Clinton and Obama discussed. These are (1) administered by the insurance industry and (2) way out of reach for the uninsured and underinsured, thus would at least require colossal government subsidy, way beyond the $600 billion ā€œdown payment.ā€ Baucus also supports a ā€œmandateā€ that criminalizes the uninsured.

The ā€œpublic plan optionā€ will not expand our choice of caregivers, will not be universal, cannot offer comprehensive care (and thus can not lessen disparities in care or improve quality) ā€” and above all there will be no way to pay for it, especially as the economy continues to tank. We should conclude that it is not reform!

We should also recognize, with confidence in people to decide and act for themselves, that the single payer cause is growing into a mass movement for civil rights. We may not be likely to win single payer this spring, but as the only proposal for health reform that will save hundreds of billions of dollars annually, that is comprehensive and just and practical, our prospects will continue to brighten, no matter what inside-the-beltway compromise people like Dr. Dean ultimately recommend we make with the insurance industry.

Answer by Dr. Don McCanne

The option to purchase a public plan within a market of private health insurance plans would merely provide one more player in our inefficient, dysfunctional, fragmented, multi-payer system of financing health care, that is if the public option even survives the political process. It would leave in place the deficiencies that have resulted in very high costs with the poorest health care value of all nations (i.e., overpriced mediocrity in health care).

Those who believe that the people of this nation would have the wisdom to drop their private plans and join the government program are ignoring history. When Congress authorized private plans to compete with our existing public program, Medicare, many enrollees did just the opposite. One-fifth have left the traditional Medicare program and joined the private plans.

So why should we care? Why shouldnā€™t they have the right to choose private plans if they want them? We know that those private plans are wasting money, both in their own costs and the administrative burden they place on the delivery system, but what all too many donā€™t realize is that we are all paying for that waste because of the inherent structural deficiencies in our financing system. Plus we are being deprived of the reforms needed in our health care delivery system that our own single payer monopsony would bring us.

Single payer activists, donā€™t give up. As President Obama said in his press conference this week, ā€œpersistence!?

Universal healthcare is okay for a small country or organization like Switzerland, Canada, or the Veterans Administration, but it wouldnā€™t work when scaled up to meet the needs of a large country like theĀ US

Medicare is a national program that works reasonably well. There isno reason whatsoever that would make it hard to scale up. Indeed, Medicare was initiated (and administered for tens of millions of enrollees) before computers became available – scaling it up 7 or 8 fold should not prove difficult.

In Canada, health care is administered at the provincial level. The Ontario Health Insurance Program, which includes the city of Toronto as well as rural areas, is a good example. Since much of the program we envision would be regionalized, with regions similar in size to Ontario, that program seems a sound indication that scale should not be problematic.

Recent Attacks on Single Payer Health Reform: Ideology Masquerading as Scholarship

By DavidĀ U.Ā Himmelstein,Ā M.D.Ā and Steffie Woolhandler,Ā M.D., M.P.H.

Some conservative opponents of single payer health reform have been claiming that new research proves that Canadaā€™s single payer national health insurance program has performed poorly, and that projected savings on administration are illusory. In the commentaries below we analyze the two most prominent examples of this newĀ researchĀ a paper by June and Dave Oā€™Neill (ā€œHealth Status, Health Care and Inequality: Canada Vs. theĀ U.S.ā€) and a report by Bejamin Zycher (ā€œComparing Public and Private Health Insurance: Would a Single Payer System Save Enough to Cover the Uninsured?ā€).

The Oā€™Neillā€™s ā€œHealth Status, Health Care and Inequality: Canada vs. theĀ U.S.ā€œ

A recent paper by June and Dave Oā€™Neill contests previous research findings that health outcomes are better in Canada than in theĀ U.S.Ā The Oā€™Neills also claim that income-based health disparities are larger in Canada than in theĀ U.S.,Ā that access to care is better in theĀ U.S.Ā and that cancer screening and survival are worse in Canada.

The Oā€™Neills collected no new data. Their analysis rests on idiosyncratic, highly selective and overtly biased reinterpretations of previously published data ā€” mostly from the Joint Canada/U.S. Survey of Health (JCUSH), a population-based survey conducted jointly by theĀ U.S.Ā and Canadian government statistical agencies. While they extensively cite the few pieces of published data that supports their grim view of Canadaā€™s health system, they ignore a large body of research and statistics that conflicts with their portrayal.

We will briefly discuss the main assertions in the Oā€™Neill paper.

1-Canadaā€™s lower mortality rates are not a result of better health care

The Oā€™Neills assert that Canadaā€™s longer life expectancy (2 years longer) and lower infant mortality rate (5.3 deaths/1000 live births vs. 6.8 in theĀ U.S.) have nothing to do with health care. Rather, they claim that non-medical factors such as substance abuse, obesity, low education and ā€œcultural factorsā€ explain theĀ U.S.ā€™ poor performance.

They argue that high infant mortality in theĀ U.S.Ā simply reflects the high frequency of preterm births and low birth weight, and especially the very poor outcomes among African-Americans. Americanā€™s short life expectancy, they say, comes from high rates of obesity, as well as homicides and accidents.

But theĀ U.S.ā€™ high rate of prematurity and low birth weight is, largely, a result of poor care ā€” inadequately treated infections and chronic illnesses among pregnant women, and the shockingly frequent failure to deliver adequate prenatal care. 16% of pregnant women in theĀ U.S.Ā receive no care at all in the first trimester of pregnancy, far higher than in Canada.

While the Oā€™Neillā€™s dwell on the high obesity rates in theĀ U.S.Ā as an important non-medical cause of mortality differences, they ignore Canadaā€™s significantly higher smoking rate ā€” a graver threat to health than obesity. Moreover, they cite data from theĀ OECDĀ that exaggerates the obesity differences, ignoring the more reliableĀ JCUSHĀ data that they use for most of their other comparisons (presumably because theĀ JCUSHĀ found more modest differences in obesity rates).

They emphasize that accidents and homicides account for a large fraction of theĀ U.S./Canada mortality difference among young adults, age 20-24. But deaths are rare in this age group, and accident/homicides account for virtually none of the difference in older age groups, where almost all of the deaths occur. In fact, differences in heart disease cause most of the Canadian advantage ā€” a difference that almost certainly reflects, at least in part, better access to care in Canada.

The Oā€™Neills also ignore the fact that theĀ U.S.Ā had a lower infant mortality rate than Canadaā€™s until the passage of national health insurance (NHI) in Canada, after which Canadaā€™s rate fell sharply. Similarly, they never mention that most of Canadaā€™s advantage in life expectancy emerged shortly afterĀ NHIĀ was implemented.

In many of their data tables on mortality and other health measures, the Oā€™Neillsā€™ separate out white from minority Americans, and indicate that Canadiansā€™ health outcomes are similar to those of white Americans. Of course, excluding minorities in theĀ U.S.Ā means excluding one third of the entire population, and more than three quarters of the poor. In essence, they want to exclude the 100 million poorest and sickest Americans, and compare the remainder to a cross section of Canadians, including the sick and poor.

2-Other measures besides mortality rates are better indicators of the quality of health care in the two nations, and theĀ U.S.Ā comes out well on these.

The Oā€™Neillā€™s simply assert that self-reported health status (the answer to the question ā€œHow would you rate your health? Excellent, good, fair or poor?ā€) is a better measure of the impact of the health care system than are mortality rates. Yet this measure has never been validated for cross national comparisons of the type they make, and it seems very likely to be greatly affected by cultural norms. And, as with death rate comparisons, only by eliminating minority Americans from the comparison can they conclude that theĀ U.S.Ā looks slightly better than Canada.

They then compare the two nations using a ā€œhealth utility indexā€ and the percent of people with pain that limits their activities. For both of these, Canadians do better than Americans, until minorities are subtracted from the population.

Finally, they compare the prevalence of chronic condition like diabetes, emphysema and arthritis in the two nations, and the proportion of people with each condition who are getting treatment. They conclude that while slightly more Americans are chronically ill, more of them are getting treatment. But millions of uninsured Americans with chronic illnesses like diabetes or high blood pressure are unaware of their diagnoses because they canā€™t afford the doctors visit or lab test needed to make the diagnosis. Surveys will not identify undiagnosed persons as having chronic disease. Hence, the proportion getting treatment is falsely inflated in theĀ U.S.Ā Moreover, even the differences they cite to favor theĀ U.S.Ā are not statistically significant. Hence, a more accurate depiction of the data would state that among people who know of their diagnoses, rates of care are similar in the two nations.

3-More Americans get cancer screening and theĀ U.S.Ā has more high tech health resources than Canada

The Oā€™Neills cite higher screening rates in theĀ U.S.Ā for cervical cancer (PAP smears), breast cancer (mammography), colon cancer (colonoscopy or sigmoidoscopy) and prostate cancer (PSA testing). Only the smallĀ PAPĀ smear difference is real.

For mammography, they include all women 40-69 in their calculation of screening rates. But neither the American College of Physicians nor the Canadian Task Force on Preventive Health Care recommend mammograms for all women 40-50. Mammograms for women in this age group leads to more breast surgery and other cancer treatments, but has not been shown to lower overall mortality. It is likely that most of the difference in breast cancer screening is due to higher screening rates among young women in theĀ U.S.,Ā who may even be harmed by excessive mammograms.

Thereā€™s a similar problem with their analysis of colon cancer screening. They include people age 40-69. Yet standard guidelines do not recommend colon cancer screening in normal risk individuals before age 50. Theyā€™ve fudged the data to get a result they want.

Neither theĀ U.S.Ā Preventive Services Task Force nor its Canadian counterpart recommend routineĀ PSAĀ testing because its not at all clear that such testing does more good than harm ā€” it turns up lots of false positives, including many small tumors that would never cause serious problems if left untreated. Routine screening may well lead to many unnecessary operations that leave men incontinent and impotent. Yet the Oā€™Neillā€™s interpret Canadaā€™s lowerĀ PSAĀ screening rate as an indicator of poor quality care.

We may ultimately find thatĀ PSAĀ screening or early mammography saves lives ā€” or causes more harm than good. But at present, we just donā€™t know whether the lower use of these technologies in Canada is a good thing or a bad one.

Their analysis also trumpets the greater number ofĀ CTĀ scanners andĀ MRIĀ machines in theĀ U.S.Ā as an indicator of better quality. Yet recent estimates suggest that in the coming years radiation fromĀ CTĀ scans may cause as many of 2% of all cancer deaths in theĀ U.S.Ā ā€” about 30,000 excess deaths annually. It is far from clear that the greater use ofĀ CTĀ scanners in theĀ U.S.Ā (relative to Canada) causes more good than harm.

4-Waits for care compromise access in Canada, and these access problems are worse than those in theĀ U.S.

The Oā€™Neill analysis admits that fewer Canadians than Americans report an unmet health need (11.3% vs. 14.4%). In theĀ U.S.,Ā cost is the big problem, while waits for care are more prominent in Canada. They try to obfuscate the Canadian advantage on access measures by presenting a complex sub-group analysis of pain suffered by those unable to get care. But when you cut through their obfuscation, even this measure favors Canada; about 12% more Americans who say theyā€™re unable to get care report being in pain.

5-Cancer mortality rates are higher in Canada, indicating worse cancer care

The Oā€™Neills claim that mortality rates for lung, breast, colon and prostate cancers are lower in theĀ U.S.Ā than in Canada. They calculate mortality rates by dividing cancer deaths by the number of cases of cancer.

When cancer death rates are calculated in a more standard fashion, i.e. the number of deaths per thousand people in the population, age adjusted cancer mortality is actually lower in Canada than in theĀ U.S.Ā for all of these cancers except colorectal cancer. But there are more cancers diagnosed in theĀ U.S.Ā Hence, the death rate among those who are diagnosed ā€” the figure the Oā€™Neills choose as the most important – is lower in theĀ U.S.

This higher incidence of cancers diagnosed in theĀ U.S.Ā probably reflects more intensive screening programs, which diagnose more people with cancer. But, as stated above, its far from clear that diagnosing small prostate cancers based onĀ PSAĀ screening causes more good than harm. Most elderly men with prostate cancer do not die of that disease, but of heart disease or some other illness. (It is likely that some breast and lung cancers that are diagnosed through screening would also never come to light without screening.) In theĀ U.S.,these men with small, non-lethal cancers appear in the denominator of the Oā€™Neillā€™s calculation of cancer mortality rates, but not the numerator. In Canada, they appear in neither the numerator nor denominator. Thus, their estimate of cancer mortality rates is biased against Canada because of the higher screening rate in theĀ U.S.

6-Income-based health disparities are, if anything, steeper in Canada than in theĀ U.S.

The Oā€™Neills admit that health differences between those above and below the median income are sharper in theĀ U.S.Ā than in Canada. In fact, the differences between the top and bottom 10% are also bigger in theĀ U.S.,Ā as are those between the top and bottom 25% etc.

But the Oā€™Neills want to measure health inequities on a new scale. They observe that the rich in theĀ U.S.Ā are much richer than the rich in Canada, and the poor are much poorer. Rather than comparing high and low income persons, they decide to analyze how much worse health gets for each dollar decrease in income. Since theĀ U.S.Ā income gradient is much steeper, this analysis automatically makes the health per dollar gradient less steep. Notice that this method would find that a nation with almost no income inequality would automatically have very steep health inequalities.

Hereā€™s an example. In CountryĀ A,Ā the top 1% has an average income of $60,000 and a mortality rate of 100 per 1000. The bottom 1% has an average income of $30,000 and a mortality rate of 130 per 1000. Then, according to the Oā€™Neillsā€™ method for each $1000 increase in income, the mortality rate rises 1 per 1000.

In CountryĀ B,Ā the top 1% has an average income of $603,000 and a mortality rate of 100 per 1000. The bottom 1% has an average income of $3,000 and a mortality rate of 300 per 1000. Then, according to the Oā€™Neillsā€™ method for each $1000 increase in income, the mortality rate rises only 1 per 3000.

So the Oā€™Neillsā€™ calculus would judge the income/health gradient less steep in CountryĀ BĀ (where the poor have a death rate 300% higher than the wealthy) than in CountryĀ AĀ (where the poor have a death rate 10% higher than the wealthy).

7-Whatā€™s left out?

The Oā€™Neillā€™s paper cites dozens of references. But they fail to mention any of the numerous previous studies that directly address the questions they seek to answer. These include:

1-Previous analyses of theĀ JCUSHĀ data by the National Center for Health Statistics (http://www.cdc.gov/nchs/pressroom/04news/firstjointsurvey.htm) and by our group at Harvard (http://www.ajph.org/cgi/content/abstract/96/7/1300), which found a far different result.

2-The many published studies directly comparing the quality of medical care in the two nations for cancer patients, renal dialysis patients etc. 38 of these studies were included in a systematic review which concluded that, on average, mortality rates are 5% lower in Canada (http://www.openmedicine.ca/article/view/8/1).

3-The large body of literature showing that Canadaā€™s health care system is far more efficient, with administrative overhead that is a small fraction of theĀ U.S.Ā level (http://content.nejm.org/cgi/content/short/349/8/768)

4-A recent analysis of deaths that could be prevented by good medical care ranked theĀ U.S.worst among the 19 nations studied, well behind Canada which ranked 6th. Moreover, while Canadaā€™s ranking improved between 1997 and 2003, theĀ U.S.Ā fell further behind. (http://content.healthaffairs.org/cgi/content/abstract/27/1/58)

There is much to criticize in Canadaā€™s health care system. But the Oā€™Neillā€™s analysis strays far from legitimate scientific discourse, mixing selective citation and creative accounting that is intellectually dishonest.

Bejamin Zycherā€™s ā€œComparing Public and Private Health Insurance: Would a Single Payer System Save Enough to Cover the Uninsured?ā€

Benjamin Zycher, an economist at the right wing Manhattan Institute, has recently issued a report disputing claims that a single payer health care reform would realize large administrative and overhead savings. We will briefly respond to the main arguments in Zycherā€™s paper.

1-Medicareā€™s administrative costs are far higher than the figure given in the National Health Accounts.

The National Health Accounts indicate that administrative costs account for only 3% of total Medicare spending (vs. 14% in private insurers). But Zycher wants to add to this a proportional share of all government spending. That is, he claims that 14% of the Presidentā€™s salary, the cost of Congress, theĀ FBI,Ā the federal courts etc, should be attributed to Medicare, since Medicare accounts for 14% of federal spending. Based on this, he estimates ā€œtrueā€ Medicare administrative costs at 6% of total outlays, and concludes that potential savings on insurance overhead is only 8% of premiums, not 11%.

Zycherā€™s argument assumes that expanding Medicare to cover all Americans would drive up the costs of all government agencies, Congress etc. ā€” an absurd assumption. Would we really raise the presidentā€™s salary, or a senatorā€™s pay as part of implementing a single payer system? In fact, there is no reason to posit increases in any such costs, and the Canadian experience suggests that Medicareā€™s overhead could actually be reduced to about 1% by simplifying hospital and physician payment.

Additional information on Medicare’s administrative costs:

2011 Primer on Medicare Spending and Financing

Kaiser Family Foundation
Administrative Costs

The costs of administering the Medicare program have remained low over the years ā€“ less than 2 percent of program expenditures. As such, program administration is not a contributing factor to Medicareā€™s expenditure growth. Administrative costs include all expenses by government agencies in administering the program (HHS, Treasury, the Social Security Administration, and the Medicare Payment Advisory Commission). Also included are the cost of claims contractors and other costs incurred in the payment of benefits, collection of Medicare taxes, fraud and abuse control activities, various demonstration projects, and building costs associated with program administration.

http://www.kff.org/medicare/7731.cfm

2-The higher taxes needed to fund national health insurance would cause massive economic losses that more than offset any administrative savings.

Zycher argues that every dollar collected in taxes by the government actually costs the economy about $1.76 because of foregone private investment. He wants to add a large portion of this cost to Medicareā€™s overhead, arriving at an estimate that overhead consumes 52% of total Medicare spending.

First, his estimate of the economic consequences of taxation is questionable at best. His assumption that the taxes raised forĀ NHIĀ would come from investment, not from existing health care expenditures, is unfounded. Its simply crazy to posit that money flowing to health care through private insurers provides strikingly more stimulus to the economy than the exact same amount flowing through a government insurance plan.

3-Private insurersā€™ overhead is not really wasteful.

Zycher admits that Medicare andĀ NHIĀ achieve large savings on underwriting, advertising etc. But he argues that these activities are good things because they ā€œalign premiums with costsā€, stop the healthy from cross-subsidizing the sick, and make everybody pay the true costs of their own care. He assumes that a market-based health insurance system ā€” which minimizes risk pooling and cross-subsidies – must be most efficient. Therefore, the costs of administering such a market are, by definition, not waste but a necessary part of efficiency.

Of course, he does not and cannot adduce any evidence that a market-based health insurance system is actually efficient. In fact, the overwhelming evidence indicates that it is far less efficient thanĀ NHI.

4-What Zycher leaves out.

Zycherā€™s arguments completely ignore the massive administrative waste that private insurers inflict on hospitals, doctors, nursing homes etc. In fact, insurance overhead accounts for only one-quarter of total health care administrative costs in theĀ U.S.Ā The complexity of our current reimbursement schemes requires providers to fight with insurers for payment for every aspirin and bandaid. This requires a huge administrative staff, billing computers etc.

In contrast, a single payer system could greatly streamline providersā€™ paperwork. Paying hospitals on a lump sum budget basis ā€” e.g. as a fire department is currently paid ā€” could cut hospital administration costs in half. Similar savings could be realized by simplifying doctorsā€™ billing.

In sum, Zycherā€™s analysis falsely inflates Medicareā€™s overhead costs, makes outlandish assumptions about the economic costs of taxes vs. premiums, attributes unsubstantiated social benefits to advertising and insurance underwriting, and ignores the massive administrative burden borne by providers.

When Canada adopted single payer, did she allow labor unions to opt-out and ā€œkeep what they have.ā€

No. Neither the provinces nor the federal government ever allowed labor unions to opt-out of the plan. Confusion on this point seems to arise from two places. 1) The province of Alberta did not join the single payer system until 1968, and 2) from the beginning, for non-covered benefits only, unions and individuals could ā€œkeep what they hadā€ and could bargain for supplementary health benefits with private insurance companies.

What doesĀ PNHPĀ have to say about the primary care workforce shortage?

Countries with strong health care systems have at least half of their physicians in generalist primare care practice 50 percent in Canada, 70 percent in the United Kingdom (Starfield,Ā B,Ā Is primary care essential? Lancet 344: 1129, 1994)

In 2008, less than 8 percent ofĀ U. S.Ā seniors chose family medicine, a 50 percent decline since 1997; only 199Ā U. S,Ā seniors matched into primary care internal medicine, 248 intoĀ IM/Peds, and 53 into primary Peds. The percentage of international medical graduates (IMGā€™s) in our 3 primary care specialties is now 73 percent forĀ IM, 68Ā percent for Peds, and 55 percent for Fam. Med. (Pugno,Ā P ,Ā et al Fam Med 40 (8): 563, 2008) I donā€™t believe that we have more than about 30 percent of our physicians in primary care. Only 20 percent of internal medicine graduates become general internists, and most pediatric graduates go into sub-specialties. (Bodenheimer,Ā T.Ā Primary careā€”Will it survive?Ā NĀ EnglĀ JĀ Med 355 (9):861, 2006).

Primary care has been declining in this country for many years, as a result of multiple factors, including more attractive lifestyles and reimbursement on the non-primary care fields;student perceptions of the demands, rewards, and prestige of generalist practice; and uncertainty of the health care environment. The American College of Physicians in 2007 declared that: ā€œOur primary care infrastructure is at grave risk of collapseā€.

Single-payer national health insurance will provide an opportunity to restructure theĀ U.S.physician workforce, strenghten and rebuild primary care. We should have at least 50 percent of our physicians in primary care fields. Useful approaches include reimbursement reform, loan forgiveness programs for graduating medical students entering primary care residencies, increased funding for graduate medical education (GME) teaching programs in primary care, and reallocation ofĀ GMEĀ training slots by specialty.

Answer contributed by Dr. John Geyman,Ā PNHPĀ Past President

What is a Voucher Plan? Whatā€™s Wrong With It?

AĀ Voucher Plan is a version of health reform that seeks to provide a simplified means for individuals to purchase health insurance, while retaining the private insurance system intact. The principal advocates of this plan are Ezekiel Emanuel, a bioethicist now serving as one of President Obamaā€™s principal advisors on health care reform, and Victor Fuchs, a retired economist from Stanford University. Under this plan, individuals would be given a health care certificate, an insurance ā€œvoucher,ā€ which would entitle them to enroll in a private health plan of their choice. Employer-based insurance would be eliminated. The vouchers would, under the Emanuel-Fuchs plan, be paid for through a value-added tax (VAT), essentially a sales tax on all manufactured goods and services. This is a highly regressive way of financing such a plan, since low-income people spend a much larger percentage of their income on purchases of goods and services than do higher-income people. However, the main problem with such a plan is that it leaves the wasteful, inefficient, and inequitable private insurance system in place, with no change at all in its operation. It simply makes it easier for us to purchase their defective product.

Answer contributed by Len Rodberg, Ph.D.

What about the claim (in videos circulating on the internet) that a patient in Canada would have died of a brain tumor if he hadnā€™t come to theĀ U.S.Ā for anĀ MRI?

The video of Lindsay McCreith is by Stuart Browning who is infamous for not allowing objectivity to interfere with his anti-government messages. Also, two interests intervened during the management of McCreithā€™s care. One is a firm that arranges medical tourism to the United States, using queues as a business stimulus. The other is a law firm that specializes in cases that would promote privatization of the Canadian medicare system. Thus it began as a setup for the libertarian/conservative camp.

The claim that he would have died had he waited the four months for anĀ MRIĀ scan is an outrageous lie.Ā A C-T scan was done immediately. The tumor was identified, and it was of a nature that did not require emergency management. An emergencyĀ MRIĀ would have been done if it were indicated, but it wasnā€™t.

We do not have all of the details that would come forth during discovery, but we do have a copy of the lawsuit. When you read it, it is clear that the claim is based on ideology rather than government mismanagement. Queues are a problem, but they are being addressed, with considerable success.

If Canadians are to continue to improve queues it is very important that non-emergency patients should never be allowed to purchase a place at the front of the queue. If that were allowed, queues for individuals who could not afford to pay for private care would become intolerable, creating a two-tiered system with boutique care for the wealthy and mediocrity in a neglected system for the non-wealthy.

Here is the lawsuit. (Keep in mind that the lawsuits are filed with inflammatory language, whereas the actual facts then must be confirmed during the discovery process.)
http://www.law.utoronto.ca/healthlaw/docs/case_McCreith.pdf

This is an article on low grade astrocytoma, confirming that this was not an emergency.
http://emedicine.medscape.com/article/1156429-overview

All health care systems can be improved, but the McCreith case should not serve as a basis for Canada to trade in their egalitarian system for theĀ U.S.Ā model with its profound health care injustices that cause so much financial hardship, physical suffering and death.

How much do private insurance companies spend on overhead and profit?

Private insurance overhead and profit, on average, fluctuates between 12% and 14% nationally. This figure is somewhat lower than the 16-20% at many of the big insurers because it includes self-insured plans of many big employers that have overhead of about 6-7%. On the other hand, overhead in the individual market is often substantially higher than 20%, and in some cases above 30%.

The estimate thatĀ totalĀ administrative costs consume 31% ofĀ U.S.Ā health spending is from research by Drs. David Himmelstein and Steffie Woolhandler and published in theĀ New England Journal of Medicine in 2003. The figure would undoubtedly be higher today. Insurance overhead accounts for a minority of the overhead. Much more occurs in physiciansā€™ offices, hospitals, and nursing homes – driven by our current fragmented payment system. The fact that insurance overhead per se accounts for a minority of the bureaucratic waste in the system explains why implementing a public option plan would not achieve most of the potential bureaucratic savings that can be realized through single payer. Even with a public option, hospitals, physicians and nursing homes would still have to maintain virtually all of their internal billing and cost tracking apparatus in order to fight with private insurers.

Doesn’t the threat of filibuster prevent fundamental reform?

The filibuster prevents more than fundamental health care reform.Ā  It hobbles our democracy. For two excellent articles on why the filibuster should be eliminated and majority rule restored, see the editorialĀ “Filibustering the Public,”Ā The Nation, December 14, 2009 and Thomas Geoghegan,Ā “The Case for Busting the Filibuster,”Ā September 7, 2009.

What about the proposal to lower the eligibility age for Medicare to 55?

Lowering the eligibility age for Medicare to 55 only works if it is mandatory.Ā  Otherwise it becomes the place where all the sickest patients get dumped.Ā  That might be okay for the sick people since Medicare is often better and more secure than private coverage, but it would drive total health care costs (and premiums)Ā  up, not down.

Will the Obama health plan cover all young adults?

No.Ā  Although the Act uses various programs to expand coverage for young adults, it is a disappointment because it fails to accomplish two of the most important goals of reform. Many young adults will still be left without coverage, and the Act fails to adequately control the increases in health care costs.

A fragmented system of private plans and public programs, such as that in the Affordable Care Act, is the most expensive model of reform, and it falls short on universality and equity. The single payer model, on the other hand, is the least expensive model of comprehensive reform, and it automatically enrolls everyone, while containing costs through proven, government-administered single payer policies. It is equitably financed through the tax system based on the ability to pay, so it is affordable to everyone.

A Commonwealth Foundation Brief (“Rite of Passage: Young Adults and the Affordable Care Act,” May, 2010) describes the reasons why many will still not be enrolled in one of the programs and remain uninsured, some suggest that these programs are incremental steps that can be modified to further expand coverage. But there are no modifications that will ever ensure that everyone is enrolled. Nor will the modifications be able to adequately control costs.

The financing infrastructure of the Affordable Care Act is fatally flawed since it cannot ever reach our goals. In contrast, if we replaced the financing system with a single payer national health program, such as an improved Medicare that automatically covered everyone, we could eliminate the profound administrative excesses of our current fragmented financing system, and use global budgets for hospitals, negotiated rates for health care professionals, and bulk purchasing of pharmaceuticals and supplies to slow the intolerable increases in health care costs. Those economic tools are effective in a truly universal system, but really don’t work in a dysfunctional, fragmented system such as that of the Affordable Care act.

Answer contributed Don McCanne, M.D., PNHP Senior Health Policy Fellow

The number of uninsured Americans now exceeds 50.7 million people according to the Census Bureau.Ā  Won’t the Obama health plan cover them?

The Patient Protection and Affordable Care Act (PPACA) will reduce the numbers of uninsured starting in 2014 (with about half of the new coverage being Medicaid, and the other half private plans) but by 2019 it is estimated it will still leave 23 million of the 50.7 million Americans identified as being uninsured without coverage.

However, it is important to note that the CBO estimate of 23 million uninsured does not include a whole additional category of people who face barriers to accessing care:Ā  People who are underinsured, who will face financial hardship should medical needs arise.Ā  Underinsurance will actually increase under PPACA.

Here’s why PPACA is an underinsurance program: Employers will see little relief and will expand their present trend of shifting more insurance and health care costs onto their employees. Individuals buying plans in the new insurance exchanges will select underinsurance products with low actuarial values (30 to 40 percent of costs must be paid by the patient) with subsidies that are inadequate to avoid financial hardship. Many will move into the Medicaid program which has more expansive coverage, but which reimburses providers at such a low rate that far too many will not be willing to accept patients under this program. With Medicaid chasing away providers, it too has become another form of underinsurance.

Thus the touted increase in insurance enrollment under PPACA will be more than offset by the explosion in underinsurance – affecting the majority of Americans.

What about report cards on physicians? Won’t they reduce costs and improve quality?

The best study of the impact of report cards on providers (a study of heart surgeons in New York) found they actually increased costs, worsened care, and inevitably gave physicians incentives to avoid the sickest patients.Ā  Several papers have documented the destructive effect of the NY Dept of Healthā€™s heart surgery report cards. The best is by Dranove et al,Ā available here.

Hereā€™s a quote from the Dranove paper:

ā€œ[O]ur results show that report cards [on heart surgeons] led to increased expenditures for both healthy and sick patients, marginal health benefits for healthy patients, and major adverse health consequences for sicker patients. Thus, we conclude that report cards reduced our measure of welfare over the time period of our studyā€ (p. 577). ā€œ[M]andatory reporting mechanisms inevitably give providers the incentive to decline to treat more difficult and complicated patientsā€ (p. 581).

ā€“ David Dranove et al., ā€œIs more information better? The effects of ā€˜report cardsā€™ on health care providers,ā€ Journal of Political Economy 2003;111:555-588

Why are health care costs rising and how can single payer “bend the cost curve”?

High administrative costs and excessive – and even ridiculous – prices under the current system are themselves symptoms of the increasing commercialization of health care and the growing dominance of private firms in health care delivery and financing.Ā  Cutting administrative costs and mandating reasonable pricing would result in very large one-time savings and allow an affordable transition to comprehensive coverage of the un- and under-insured, but without other cost control mechanisms these savings would soon be eaten up by continued health care inflation.

Over the longer term, the keys to savings lie in improved health planning implemented through control of capital spending, as well as limitations on market incentives and limitations on for-profit involvement in health care delivery.

– Health planning to assure that investments in expensive new technology meet needs, but do not exceed them, is the only proven means to limit the excessive and dangerous interventions that drive up costs and lower quality.Ā  It is the salutary alternative to the current strategies of case-by-case review by HMOs, or the potentially disastrous incentives offered under capitation arrangements.

– Limits on for-profit ownership and excessive compensation of health care executives are needed to dull the incentives for institutional gain at the expense of system-wide performance. Ā For-profit hospitals and dialysis facilities paid by Medicare have higher costs and lower quality than non-profits. Ā Elminating them is key to “bending the cost curve.”

What is PNHP view of ACO’s?

While the term ACO remains at best vaguely defined, the concept is hauntingly similar to the capitated managed care experiment that proved disastrous in the 1990s.Ā  In both instances, providers receive a set annual payment to cover the costs of all care, and get to keep whatever they don’t spend on patients.Ā  The obvious winning strategy – from a business point of view – is to recruit relatively healthy patients, offering luxuriousĀ  care for the healthy and minimally ill, and subtle cues that those with expensive illness would be better off elsewhere.Ā  Neither risk adjustment nor quality monitoring schemes are up to the task of blunting these incentives.

An ACO can game risk adjustments by ferreting out additional diagnoses that may be clinically unimportant but would up its capitation payment, and make its outcomes look better as well.Ā  The Dartmouth group has already shown that more expensive providers label their patients with more diagnoses in this way.Ā  Quality monitoring efforts measure only a tiny slice of what’s important in medicine.Ā  Overarching measures of quality like death rates and family/community well being are either too rare to measure in a statistically reliable manner, too subtle to capture with current or foreseeable measurement strategies, or too biased by differences in the baseline health of enrollees.Ā  Evidence from the UK shows that providers will improve on the aspects of care that are measured, but neglect those that are not, and it’s far from clear that monitoring of quality measures has actually improved quality or can prevent abuses.

In sum, the ACO strategy remains an untested theory for health reform.Ā  Considerable experience with similar reforms in the past suggests that this ACO strategy will lead to yet another health policy dead end.

Answer contributed by Drs. Steffie Woolhandler and David Himmelstein

What is PNHP’s perspective on the Medicare crisis?

Medicare can only be saved by incorporating it in a single payer program that would be very different than the current Medicare program.

1)Ā  Medicare benefits need to be greatly upgraded.Ā  At present, Medicare covers less than half of the total medical expenses incurred by its beneficiaries.

2) Medicareā€™s payment policies for physicians, hospitals, home care, rehab, nursing homes and HMOs are all deeply flawed.

– Its physician fee schedule is wildly skewed toward specialist care and needlessly complex; it discourages salaried practice.
– Its hospital payment system uses per-patient payments rather than global budgeting, and lumps together capital and operating payments ā€“ negating any real health planning possibilities.
– Its rehab and nursing home payment methods are similarly complex, discourage health planning, and reward institutions willing and able to engage in financial scheming.
-The home care payment system burdens nurses with extreme amounts of paperwork, rather than paying home care agencies lump sum budgets.

3) As long as Medicare is one among many payers it cannot achieve substantial administrative savings (in doctors’ offices, hospitals, and other facilities) and it cannot enforce the health planning changes needed to ā€œbend the cost curveā€ over the long term.

In short, the only way to preserve Medicare is to replace it with a single payer program with comprehensive benefits and effective cost controls (negotiated fees, global budgets, and bulk purchasing) ā€“ not just incrementally expand it to the whole population.

Answer contributed by David Himmelstein and Steffie Woolhandler

What is driving an epidemic of adverse reactions to medications in the U.S.? What impact could a single payer system have on this epidemic?

There is an epidemic of adverse side effects because of the activities of the pharmaceutical manufacturers, who seek to maximize profits regardless of the risks to patients through a variety of means such as: promoting drugs to physicians for uses they are not approved for; giving physicians incentives to prescribe medications that are more costly than alternatives; developing new medications under patent that are no better – and often worse – than older, cheaper treatments; and $4 billion in direct to consumer advertising annually. The drug companies are much stronger under multi-payer systems than single-payer systems. Single-payer systems are stronger, more active buyers or payers. They demand evidence that new drugs are clinically better, not just better than placebos and against surrogate end points. They have a societal charge to maintain and restore the health of all residents, not just the subscribers for a given insurer or payment plan. Companies are single-minded in maximizing sales and profits and thus play payers off each other. Research shows that 60% of pharmaceutical revenues are derived from new drugs with few advantages, not from breakthrough drugs – a strong incentive for companies to churn out scores of new drugs of little benefit but with under-tested risks of harm.

Answer contributed by Donald Light, Ph.D.

What about pushing to make health care a “human right”?Ā  Is that a good strategy?

PNHP fully endorses advocacy for health care as a human right as part of a single payer campaign. But some have adopted the “health care as a human right” slogan as a cover for inadequate reforms and retreat from confrontation with the powerful forces that ruin our health care system. PNHP has embraced not just a laudable moral stance, but a rigorous approach to health policy evidence and a clear vision of how morality can be achieved – with single payer national health insurance.

US infant mortality is not high compared to other countries.Ā  It just appears that way because of the way we classify life births

In 2005, the U.S. ranked 30th in the world in infant mortality. The most rigorous investigation of infant mortality in the U.S. and Europe found that even excluding infants < 22 weeks, the U.S. has appallingly high infant mortality (5.8 per 1,000 births versus 3.0 in Norway and Sweden).Ā  Much of the excess mortality is related to the much higher proportion of premature births in the U.S, the period when infant mortality is greatest.Ā  If the U.S. had the same distribution of births by gestational age as Sweden, nearly 8,000 infant deaths would be averted each year, and the U.S. infant mortality rate would be 1/3 lower.Ā  The Infant mortality rate in the U.S. for preterm (< 37 weeks) births is comparable to that of European countries, but for infants born at 37 or more weeks, the U.S. infant mortality rate is the highest. (Behind International Rankings of Infant Mortality:Ā How the United States Compares with Europe, Marian MacDorman and T.J. Mathews, IJHS, Vol 40, No 4, 2010).

Can the ACA exchanges serve as a stepping stone to single-payer reform?

A properly structured single payer system is administratively very simple, requiring little complex bureaucratic infrastructure.Ā  Moreover, most of the needed infrastructure already exists within the Medicare program.Ā  While Medicare charges co-payments and deductibles that should be entirely eliminated, its process to determine covered services (and current list of current services) is generally sound, and there is no reason to reinvent that wheel.Ā  The only real work needed on the benefit package is the inclusion of outpatient prescription drugs, long term care and dental care.Ā  For outpatient prescription drugs, some of the Canadian provincial programs have in place reference pricing systems that work well and should be copied.

Most of the complexity regarding the benefit package derives from the impulse to charge (and hence determine the levels of and exemptions from) copayments and deductibles.Ā Ā  Such charges are highly regressive (i.e. they take a far larger share of the income of the poor than of the rich); discourage needed and unneeded care to the same degree; and do not result in system-wide savings since providers increase the care provided to the wealthy to make up for lost income due to reductions in care for the poor.Ā  This was clearly demonstrated in both Quebec and Manitoba, where the abolition of out-of-pocket payments resulted in virtually no overall cost increase, just a shift of care from the healthy and wealthy to the sick and poor.Ā  Moreover, the institution of co-payments in Manitoba (when a Conservative government came to power) resulted in no net savings.Ā  Limiting the supply of expensive testing equipment, inpatient beds, and specialists has been the key to cost containment in successful single payer systems.

Adopting a Blue Cross or other private insurer’s benefits package would be a serious error.Ā  Our studies (together with Elizabeth Warren) have found that three quarters of those bankrupted by illness or medical bills were privately insured.Ā  Since Blue Cross was the dominant insurer in several of the states we have studied, it is clear that its benefit package left a very large number of its enrollees vulnerable to medical bankruptcy.
Medicare also provides a simple model for the enrollment process.Ā  It uses the Social Security records to identify all eligible persons.Ā  Since Social Security maintains current addresses for registered individual, gleaning a list of the vast majority of state residents eligible for a state single payer system should be simple, leaving only the task of enrolling the relatively small number of individuals without Social Security numbers.

Paying providers should also be simple if a single payer plan is properly structured, and here too Medicare provides much of the needed infrastructure.Ā  Medicare has collected detailed financial data for decades from every hospital, home care agency and dialysis center.Ā  Hence, determining these institutions global budgets should be a fairly simple matter.Ā  Virtually every outpatient fee-for-service provider also has a UPIN number.Ā  Of course, Medicare also has an extensive infrastructure for disbursing payments to fee-for-service providers.Ā  So the only substantive administrative task needed to implement a single payer system on the outpatient side is revising Medicare’s fee schedule.Ā  It is only the introduction of complex, untested and highly questionable new payment strategies that demands a large new administrative effort.Ā  ACO-type payment schemes are already triggering a sharp upswing in these costs.

Some have suggested that implementation of Canada’s provincial programs would have been faster had they laid the groundwork in advance using structures like the ACA exchanges. History suggests that this is a curious claim.Ā  Saskatchewan’s medical care legislation was passed in November of 1961 and initially scheduled for implementation on April 1, 1962.Ā  Implementation was delayed until July 1, 1962, but resistance from physicians (and an eventual physician strike) caused the delay, not any lack of administrative infrastructure.Ā  How much faster than five months could this program have been implemented?Ā  The situation was similar in other provinces, where any delays in implementation were largely attributable to physician and business opposition rather than administrative difficulties.Ā  Experience with the implementation of U.S. Medicare is also apropos.Ā  That program went live about 9 months after its passage, and implementation required inspections of all hospitals to assure their compliance with desegregation, and did not enjoy the advantage of a pre-existing Medicare infrastructure that we have today.

Others have suggested that Switzerland and Germany can provide useful expertise in this stage of health reform, and that their systems provide possible models of a bridge to single payer. Switzerland and Germany have among the highest administrative costs of health care system besides the U.S.Ā  The Swiss system has the highest out-of-pocket costs in the world as well as relatively high overall costs, and studies show a sharp income gradient in access to care, with the poor facing grave difficulties.Ā  Far from being a stepping stone to single payer, the Swiss reform was opposed by progressives in that nation who viewed it as a significant backward step from its previous system.Ā  Similarly the German system, in place since the 1880s, is hardly a stepping stone to a single payer system.Ā  On the contrary, it is being invaded by for-profit hospitals and is struggling with costs and administrative complexity.

The notion that the ACA infrastructure provides a useful taking off point for single payer is false. Quite the contrary, as Massachusetts experience has shown, the exchange introduces additional administrative complexity and cost (a 3% add on to premiums in Massachusetts).

– Answer contributed by Drs. David Himmelstein and Steffie Woolhandler

Why is important to prohibit hospitals and health systems from retaining an operating surplus?

Allowing hospitals and other health institutions to retain surplus operating funds delegates health planning decisions to those institutions. It means that financially successful ones can expand and modernize, while those with no surplus will decay and eventually close. As a result, institutional leaders must focus on financial success – the essence of a market-driven medical care system. This market mechanism breeds most of the bad behaviors that we decry in medicine. Allowing the market to determine success, indeed survival, means that institutional leaders must avoid unprofitable patients, services and communties (which will exist under any payment system that we can imagine), and embrace profitable ones. it means that instead of capital investments going to the areas of greatest need they will be directed to areas most likely to produce future surplus. At present, nearly 70% of all health care funds – and hence capital funds – come from public sources. This figure would rise under a single payer system. Decisions about capital investments – which are the key decisions about the future of health care – should be made by an explicit, community-controlled process, not by the market.

– Answer contributed by Dr. David Himmelstein

Statement of Dr. Marcia Angell introducing the U.S. National Health Insurance Act

Concurrent with the publication of the Physiciansā€™ Proposal for National Health Insurance in theĀ JAMA, the proposal was adapted into legislative form by Congressmen John Conyers (D-MI), Dennis Kucinich (D-OH) and Jim McDermott (D-WA).

TheĀ U.S.Ā National Health Insurance Act (also known as the Expanded and Improved Medicare for All Act),Ā HR 676,Ā was introduced on February 4, 2003. The following is the statement made at the introduction ceremony by Physiciansā€™ Working Group member and formerĀ NEJMĀ editor Dr. Marcia Angell.

(A printable handout of this document is available byĀ clicking here)

February 4, 2003
WashingtonĀ D.C.

We are here today to introduce a national health insurance program. Such a program is no longer optional; itā€™s necessary.

Americans have the most expensive health care system in the world. We spend about twice as much per person as other developed nations, and that gap is growing. Thatā€™s not because we are sicker or more demanding (Canadians, for example, see their doctors more often and spend more time in the hospital). And itā€™s not because we get better results. By the usual measures of health (life expectancy, infant mortality, immunization rates), we do worse than most other developed countries. Furthermore, we are the only developed nation that does not provide comprehensive health care to all its citizens. Some 42 million Americans are uninsured ā€” disproportionately the sick, the poor, and minorities ā€” and most of the rest of us are underinsured. In sum, our health care system is outrageously expensive, yet inadequate. Why? The only plausible explanation is that thereā€™s something about our system ā€” about the way we finance and deliver health care ā€” thatā€™s enormously inefficient. The failures of the system were partly masked during the economic boom of the 1990ā€™s, but now they stand starkly exposed. There is no question that with the deepening recession and rising unemployment, in the words of John Breaux, ā€œThe system is collapsing around us.ā€

The underlying problem is that we treat health care like a market commodity instead of a social service. Health care is targeted not to medical need, but to the ability to pay. Markets are good for many things, but they are not a good way to distribute health care. To understand whatā€™s happening, letā€™s look at how the health care market works.
Most Americans receive tax-free health benefits from their employers, who pay insurers a portion of the premiums for health coverage. But not all employers offer benefits, and when they do, the benefits may not be comprehensive. Itā€™s; entirely voluntary. When employers are competing for workers, they offer good benefits; when unemployment rises, they drop them.

The insurers with whom employers do business are mostly investor-owned, for-profit managed care businesses. They try to keep premiums down and profits up by stinting on medical services. In fact, the best way for insurers to compete is by not insuring high-risk patients at all; limiting the coverage of those they do insure (for example, by excluding expensive services, such as heart transplantation); and by passing costs back to patients by denying claims or as deductibles and co-payments. We are the only nation in the world with a health care system based on dodging sick people. These practices add greatly to overhead costs because they require a mountain of paperwork. They also require creative marketing to attract the affluent and healthy and avoid the poor and sick. Not surprisingly, theĀ U. S.Ā has by far the highest overhead costs in the world.

Itā€™s instructive to follow the health care dollar as it wends its way from employers toward the doctors and nurses and hospitals that actually provide medical services. First, private insurers regularly skim off the top a substantial fraction of the premiums ā€” anywhere from 10 to 25 percent ā€” for their administrative costs, marketing, and profits. The remainder is then passed along a veritable gauntlet of satellite businesses that feed on the health care industry, including brokers to cut deals, disease-management and utilization review companies, drug-management companies, legal services, marketing consultants, billing agencies, information management firms, and so on and so on. Their function is often to limit services in one way or another. They, too, take a cut, including enough for their own administrative costs, marketing, and profits. I would estimate that no more than 50 cents of the health care dollar actually reaches the providers ā€” who themselves face high overhead costs in dealing with multiple insurers.

What are the signs of the imminent collapse of this system? Private health insurance premiums are now rising at an unsustainable rate of about 13 percent per year, and as much as 25 percent in some areas of the country. Coverage is shrinking, as more employers decide to cap their contributions to health insurance and workers find they cannot pay their rapidly growing share. And finally, with the rise in unemployment, more people are losing what limited coverage they had. This is not a system that can be tinkered with. It needs to change.

The program we are introducing today is the very soul of simplicity and efficiency, compared with our private health care system. It is a single-payer system, that is, health care funds would be distributed by a single, public entity, so that health care could be coordinated to eliminate both gaps and overlap. In many ways, our program would be tantamount to extending Medicare to the entire population. Medicare is, after all, a government-financed single-payer system embedded within our private, market-based system. Itā€™s by far the most efficient part of our health-care system, with overhead costs of less than 3 percent, and it covers virtually everyone over the age of 65, not just some of them. Medicare is not perfect, but it is by far the most popular part of theĀ U. S.Ā health care system, and in my opinion its problems would be relatively easy to remedy ā€” but that is another subject.

What are the usual objections to the sort of national program we are calling for today? They are mostly based on a number of myths.

Myth #1 is that we canā€™t afford a national health care system, and if we try it, we will have to ration care. My answer is that we canā€™t afford not to have a national health care system. A single-payer system would be far more efficient, since it would eliminate excess administrative costs, profits, cost-shifting and unnecessary duplication. Furthermore, it would permit the establishment of an overall budget and the fair and rational distribution of resources. We should remember that we now pay for health care in multiple ways ā€” through our paychecks, the prices of goods and services, taxes at all levels of government, and out-of-pocket. It makes more sense to pay just once.

According to Myth #2, innovative technologies would be scarce under a single-payer system, we would have long waiting lists for operations and procedures, and in general, medical care would be threadbare and less available. This misconception is based on the fact that there are indeed waits for elective procedures in some countries with national health systems, such as theĀ U. K.Ā and Canada. But thatā€™s because they spend far less on health care than we do. (TheĀ U. K.Ā spends about a third of what we do per person.) If they were to put the same amount of money as we do into their systems, there would be no waits and all their citizens would have immediate access to all the care they need. For them, the problem is not the system; itā€™s the money. For us, itā€™s not the money; itā€™s the system.

Myth #3 is that a single-payer system amounts to socialized medicine, which would subject doctors and other providers to onerous, bureaucratic regulations. But in fact, although a national program would be publicly funded, providers would not work for the government. Thatā€™s currently the case with Medicare, which is publicly funded, but privately delivered.

As for onerous regulations, nothing could be more onerous both to patients and providers than the multiple, intrusive regulations imposed on them by the private insurance industry. Indeed, many doctors who once opposed a single-payer system are now coming to see it as a far preferable option.

Myth #4 says that the government canā€™t do anything right.Ā Some Americans like to say that, without thinking of all the ways in which government functions very well indeed, and without considering the alternatives. I would not want to see, for example, theĀ NIH,Ā the National Park Service, or theĀ IRSĀ privatized. We should remember that the government is elected by the public and we are responsible for it. An investor-owned insurance company reports to its owners, not to the public.

Some people say that a single-payer system is a good idea, but politically unrealistic. That is a self-fulfilling prophecy. In my opinion, the medical profession and the public would be enthusiastic about a single-payer system if the facts were known and the myths dispelled. Yes, there would be powerful special interests opposing it and I donā€™t underestimate them, but with courageous leadership, such as Representative Conyers is providing, and the support of the medical profession and public, I believe there is nothing unrealistic about a National Health Insurance Program.

I want to mention one final and very important reason for enacting a national health program. We live in a country that tolerates enormous disparities in income, material possessions, and social privilege. That may be an inevitable consequence of a free market economy. But those disparities should not extend to denying some of our citizens certain essential services because of their income or social status. One of those services is health care. Others are education, clean water and air, equal justice, and protection from crime, all of which we already acknowledge are public responsibilities. We need to acknowledge the same thing for health care. Providing these essential services to all Americans, regardless of who they are, helps ensure that we remain a cohesive and optimistic country. It says that when it comes to vital needs, we are one community, not 280 million individuals competing with one another. In seeking to ensure adequate health care for all our citizens, we have an opportunity today to reassert that we are indeed a single nation.

Marcia Angell,Ā M. D.
Senior Lecturer, Department of Social Medicine, Harvard Medical School
Former Editor-in-Chief, New England Journal of Medicine

Key Features of Single-Payer

  • Universal, Comprehensive CoverageĀ 
    Only such coverage ensures access, avoids a two-class system, and minimizes expense
  • No out-of-pocket payments
    Co-payments and deductibles are barriers to access, administratively unwieldy, and unnecessary for cost containment
  • A single insurance plan in each region, administered by a public or quasi-public agencyĀ 
    A fragmentary payment system that entrusts private firms with administration ensures the waste of billions of dollars on useless paper pushing and profits. Private insurance duplicating public coverage fosters two-class care and drives up costs; such duplication should be prohibited
  • Global operating budgets for hospitals, nursing homes, allowed group and staff modelĀ HMOs and other providers with separate allocation of capital fundsĀ 
    Billing on a per-patient basis creates unnecessary administrative complexity and expense. A budget separate from operating expenses will be allowed for capital improvements
  • Free Choice of Providers
    Patients should be free to seek care from any licensed health care provider, without financial incentives or penalties
  • Public Accountability, Not Corporate Dictates
    The public has an absolute right to democratically set overall health policies and priorities, but medical decisions must be made by patients and providers rather than dictated from afar. Market mechanisms principally empower employers and insurance bureaucrats pursuing narrow financial interests
  • Ban on For-Profit Health Care Providers
    Profit seeking inevitably distorts care and diverts resources from patients to investors
  • Protection of the rights of health care and insurance workers
    A single-payer national health program would eliminate the jobs of hundreds of thousands of people who currently perform billing, advertising, eligibility determination, and other superfluous tasks. These workers must be guaranteed retraining and placement in meaningful jobs.

from the American Journal of Public Health January 2003, Vol 93, No.1

Beyond the Affordable Care Act: A Physiciansā€™ Proposal for Single-Payer Health Care Reform

Dear colleague,

We invite you to add your name to the list of endorsers ofĀ ā€œBeyond the Affordable Care Act: A Physiciansā€™ Proposal for Single-Payer Health Care Reform,ā€Ā which is displayed below. (To view a PDF of the proposal and other, supplemental materials,Ā click here. To read and view media coverage of the proposal,Ā click here. To access content from the May 5, 2016 news conference,Ā click here.)

This proposal was drafted by the 39 member Working Group on Single-Payer Program Design. It was published in the June 2016 issue of theĀ American Journal of Public Health, and has been endorsed by 2,525 other physicians and 186 medical students to date. (See below for a complete list of endorsers.)

Thank you for partnering with us in this effort.

Sincerely,

The Working Group on Single-Payer Program Design

Co-chairs:*

Adam Gaffney, M.D., Pulmonary & Critical Care Fellowship Program, Massachusetts General Hospital

David U. Himmelstein, M.D., Professor of Public Health, City University of New York; Lecturer in Medicine, Harvard Medical School

Steffie Woolhandler, M.D., M.P.H., Professor of Public Health, City University of New York; Lecturer in Medicine, Harvard Medical School

Marcia Angell, M.D., Former Editor-in-Chief, New England Journal of Medicine; Senior Lecturer, Department of Global Health and Social Medicine, Harvard Medical School

* Affiliations listed for identification purposes only and do not imply institutional endorsement.

Endorsement Options

I am a physician or medical studentĀ and I wish to endorse the Physiciansā€™ Proposal for Single-Payer Health Care Reform.

I am a non-physician health professional or a reform advocate outside the health professionsĀ and I wish to endorse the Physiciansā€™ Proposal for Single-Payer Health Care Reform.

I am authorized to speak on behalf of my institution, and my institution wishes to endorse the Physicians’ Proposal for Single-Payer Health Care Reform.

I am unable to endorseĀ the Physiciansā€™ Proposal for Single-Payer Health Care Reform at this timeĀ but would like to make a donationĀ to further this effort.

Abstract

Even after full implementation of the Affordable Care Act (ACA), tens of millions of Americans will remain uninsured or only partially insured, and costs will continue to rise faster than the background inflation rate. We propose to replace the ACA with a publicly financed National Health Program (NHP) that would fully cover medical care for all Americans, while lowering costs by eliminating the profit-driven private insurance industry with its massive overhead.Ā  Hospitals, nursing homes, and other provider facilities would be nonprofit, and paid global operating budgets rather than fees for each service. Physicians could opt to be paid on a fee-for-service basis, but with fees adjusted to better reward primary care providers, or by salaries in facilities paid by global budgets.Ā  The initial increase in government costs would be offset by savings in premiums and out-of-pocket costs, and the rate of medical inflation would slow, freeing up resources for unmet medical and public health needs.

Click on each section to see text.

Endorsement Options

I am a physician or medical studentĀ and I wish to endorse the Physiciansā€™ Proposal for Single-Payer Health Care Reform.

I am a non-physician health professional or a reform advocate outside the health professionsĀ and I wish to endorse the Physiciansā€™ Proposal for Single-Payer Health Care Reform.

I am authorized to speak on behalf of my institution, and my institution wishes to endorse the Physicians’ Proposal for Single-Payer Health Care Reform.

I am unable to endorseĀ the Physiciansā€™ Proposal for Single-Payer Health Care Reform at this timeĀ but would like to make a donationĀ to further this effort.

Doctor arrested at Trump’s Nashville rally arrested again in D.C.

By Marion Kirkpatrick
WSMV-TV (Nashville), July 18, 2017

Dr. Carol Paris, one of several protesters arrested at President Donald Trumpā€™s rally in Nashville in March, was arrested again on Monday a protest in Washington D.C.

ā€œI donā€™t engage [in protests] for the fun of it,ā€ she explained in a phone interview on Tuesday. ā€œI truly believe itā€™s part of my job as a physician to not only take care of patients individually but also to do anything I can to help fix our healthcare system.ā€

Paris is president of Physicians for a National Health Program, a single issue advocacy group pushing for a national health program. She was one of the leaders of a protest against the GOP health care bill in Washington D.C. on Monday, and one of 80 people arrested there.

This isnā€™t her first brush with the law ā€“ the Nashville physician was arrested during at a protest before the passage of the Affordable Care Act in 2009. They hoped to ā€œget a seat at the table for a single-payer system.ā€

ā€œHere were are in 2017, still debating this issue. It goes back to that famous Churchill quote, ā€˜Americans will do the right thing, but only when we exhaust all the other possibilities,ā€™ā€ Paris said.

Her arrest on Monday was part of a planned event, and participants went through training with advocates and a lawyer, knowing that they could face arrest if they refused to disband when confronted by Capitol law enforcement.

Paris said all their actions were non-violent in nature, and, as she described, ā€œbeing disruptive in service of the greater good.ā€

On Wednesday, Paris said she will be back in Washington D.C. to participate in another protest at the Senate office building and participate in a national town hall on health care. She knows thereā€™s a likely possibility she could be arrested again.

ā€œI agree with Republican [leaders], ACA is not a good piece of legislation,ā€ Paris said. ā€œBut we canā€™t go back, we need to go forward, and the only solution is a national health program.ā€

When asked if she was paying for her arrest-related expenses out-of-pocket, she said yes.

ā€œItā€™s only a $50 fee, which is not an amount thatā€™s prohibitive to me,ā€ she said. ā€œSome people go and buy shoes. I post bail.ā€

http://www.wsmv.com…

Doctor arrested at Trump’s Nashville rally arrested again in D.C.

By Marion Kirkpatrick
WSMV-TV (Nashville), July 18, 2017

Dr. Carol Paris, one of several protesters arrested at President Donald Trumpā€™s rally in Nashville in March, was arrested again on Monday a protest in Washington D.C.

ā€œI donā€™t engage [in protests] for the fun of it,ā€ she explained in a phone interview on Tuesday. ā€œI truly believe itā€™s part of my job as a physician to not only take care of patients individually but also to do anything I can to help fix our healthcare system.ā€

Paris is president of Physicians for a National Health Program, a single issue advocacy group pushing for a national health program. She was one of the leaders of a protest against the GOP health care bill in Washington D.C. on Monday, and one of 80 people arrested there.

This isnā€™t her first brush with the law ā€“ the Nashville physician was arrested during at a protest before the passage of the Affordable Care Act in 2009. They hoped to ā€œget a seat at the table for a single-payer system.ā€

ā€œHere were are in 2017, still debating this issue. It goes back to that famous Churchill quote, ā€˜Americans will do the right thing, but only when we exhaust all the other possibilities,ā€™ā€ Paris said.

Her arrest on Monday was part of a planned event, and participants went through training with advocates and a lawyer, knowing that they could face arrest if they refused to disband when confronted by Capitol law enforcement.

Paris said all their actions were non-violent in nature, and, as she described, ā€œbeing disruptive in service of the greater good.ā€

On Wednesday, Paris said she will be back in Washington D.C. to participate in another protest at the Senate office building and participate in a national town hall on health care. She knows thereā€™s a likely possibility she could be arrested again.

ā€œI agree with Republican [leaders], ACA is not a good piece of legislation,ā€ Paris said. ā€œBut we canā€™t go back, we need to go forward, and the only solution is a national health program.ā€

When asked if she was paying for her arrest-related expenses out-of-pocket, she said yes.

ā€œItā€™s only a $50 fee, which is not an amount thatā€™s prohibitive to me,ā€ she said. ā€œSome people go and buy shoes. I post bail.ā€

http://www.wsmv.com…

Nashville doctor arrested in D.C. while protesting Trump’s health care plan

By Kirk A. Bado
The Tennessean, July 18, 2017

Dr. Carol Paris, one of several protesters who disrupted President Donald Trump’s Nashville rally in March, was arrested by in Washington, D.C., on Monday for protesting the Republican health care plan. 

“I can’t seem to stay out of trouble for long,” she said in a telephone interview Tuesday.

Paris is the current president of the national organization Physicians for a National Health Program and is on the steering committee of Health Over Profit for Everyone.

On Monday, she led a crowd of demonstrators in the atrium of the Hart Senate Office, decrying the Republican health care plan and imploring Congress to expand Medicare to all citizens. 

“I want you to know that doctors are not in favor of this bill. I need your support for this solution, and that is improved Medicare for all!” she said to applause from dozens of supporters.

Holding a similar small green sign she brandished during the Trump rally reading “Improved Medicare for All,” Paris led chants proclaiming health care is a human right, and demanding Congress stop the Republican plan.

The Congressional Budget Office estimated the Republican plan would leave 22 million Americans uninsured.

After about 25 minutes in the atrium, Capitol police removed Paris and several other demonstrators. Wearing her white lab coat and hands restrained behind her back, Paris was escorted out of the building.

“We knew we would be arrested,” she said. “We met with a lawyer and were ready.”

Unlike in Nashville when she was simply told to leave the facility, the Tennessee physician was processed by the police. She paid the $50 fine to have her case resolved through the “post and forfeit” method.

The Republican health care plan seems to have stalled in the Senate, after several key Senators came out against the bill. On Wednesday, Paris plans to help lead a health care town hall before helping participants meet with Senators.

Now, Paris wants to urge Congress to keep the framework of the Affordable Care Act viable through the government sponsored subsides. Trump has threatened to cut off those funds in a message posted on Twitter Tuesday morning.

“The message is that we are not going away and you are energizing us,” said Paris.

http://www.tennessean.com…

Where now on health care reform?

By Sen. Mitch McConnell
Press Release, July 17, 2017

U.S. Senate Majority Leader Mitch McConnell (R-KY) made the following statement regarding a vote to repeal Obamacare:

ā€œRegretfully, it is now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful.

ā€œSo, in the coming days, the Senate will vote to take up the House bill with the first amendment in order being what a majority of the Senate has already supported in 2015 and that was vetoed by then-President Obama: a repeal of Obamacare with a two-year delay to provide for a stable transition period to a patient-centered health care system that gives Americans access to quality, affordable care.ā€

https://www.mcconnell.senate.gov…

***

By Donald J. Trump
Twitter, July 17, 2017

Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate. Dems will join in!

https://twitter.com…

***

Comment:

By Don McCanne, M.D.

Just what Quote of the Day readers need – one more opinion amongst the plethora of reactions to the failure of Sen. McConnellā€™s effort to herd through a bill that could be labeled as ā€œrepeal and replacement of Obamacare.ā€ But instead of predicting what might or will happen, letā€™s skip forward to what the response of single payer advocates should be. There will be no surprises here.

The Republicans want something that they can cite as fulfilling their six year long promise to repeal Obamacare, but that has been complicated by the revelation that their replacement proposals are ā€œmeanā€ and thus opposed by the majority of Americans.

Without going into the various permutations and combinations of what the politicians may do, a few facts stand out:

* The Republican replacement proposals really are mean. Through several mechanisms they would make paying for health care more of an individual responsibility when health care has become so expensive that many Americans simply would be unable to pay the out-of-pocket expenses that the Republican proposals would require. More physical suffering and financial hardship would be inevitable.

* The desire to repeal and replace the Affordable Care Act has been based on the very real deficiencies that have left too many Americans uninsured and underinsured. The Democratic politicians are making overtures that they are willing to work with the Republicans as long as the Medicaid expansions and the improvements in the individual insurance market are protected. Although a few Republicans might find some common ground here on policy, the majority would reject this as an acknowledgement of the defeat of their effort to repeal Obamacare, a bitter pill to swallow considering the intensity and passion of their opposition.

* The concept of single payer – an improved Medicare for all – continues to grow in popularity and is now favored by a majority of Americans. Even a majority of Democrats in the House of Representatives have now agreed to cosponsor John Conyersā€™ H.R. 676 – the Expanded & Improved Medicare for All Act.

* Although the Democrats in Congress are now coming out and saying that they support single payer, most of them say that our task now instead is to protect the Affordable Care Act. And after this crisis has been averted? They say that we should elect more Democrats in  2018 1n 2020 so that we can move forward with real reform – enacting a ā€œpublic optionā€ and maybe even enacting a Medicare buy-in for those over 55! Sorry. You can consult the PNHP website to see why these proposals would have hardly even a negligible impact on the health care problems that face us today. The Democratic position is essentially an endorsement of the unsatisfactory status quo.

So what are we to do? Just what we are doing, but a whole lot more of it. We cannot let Americans forget that the Democratsā€™ Affordable Care Act is grossly inadequate and fundamentally is not amenable to patches. We cannot let Americans forget that the Republican replacement promises proved to be mean (catching even Republicans off guard).

But, above all, we have to emphatically reinforce in the minds of Americans what it is that they find captivating in the single payer model of reform – affordable, accessible, equitable health care for all. Thatā€™s right. No surprises. Just health care justice for all.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Protesters Rally Against GOP Health Care Plan At Senate Office Building

Multiple demonstrators were arrested.

By Kaeli Subberwal & Mollie Reilly
HuffPost, July 17, 2017

Protesters again took to Capitol Hill on Monday to protest Senate Republicansā€™ proposed health care bill, staging a demonstration in the Hart Senate Office Building, where several people were arrested.

Demonstrators there urged Republican senators to vote against the bill, which would dismantle key portions of the Affordable Care Act and cause millions of people to lose their health care coverage, largely due to cuts to Medicaid.

According to a Capitol Police spokeswoman, five adults were arrested in the atrium of the Hart Senate Office Building. Police also responded to demonstrations in five other locations in the U.S. Capitol, arresting 33 people in total.

ā€œThose who refused to cease and desist were placed under arrest,ā€ she said.

Protesters gathered in the buildingā€™s lobby in front of the towering metal sculpture, ā€œMountains and Clouds,ā€ and took turns explaining how the bill would affect their lives.

One protester explained that she has to visit specialized doctors every six months to check on the progress of her condition.

ā€œI canā€™t go without treatment. I canā€™t go without insurance. And I do need Medicaid,ā€ she said. ā€œSo Iā€™m asking the president to stop attacking the American people. Iā€™m asking the GOP to stop attacking the American people. Iā€™m asking to kill this bill and save us.ā€

The protesters then took up a chant of ā€œkill the bill.ā€

Dr. Carol Paris, the president of Physicians for a National Health Program, spoke about the negative impact that the bill would have on patients.

Police officers were gathered around the entrance to the building, and after several speakers and many chants of ā€œweā€™re ready to fight, health care is a human right,ā€ they asked people who were gathered around the protesters to move away from the front of the sculpture.

A small group of protesters remained in front of the mountainous structure chanting, and appeared willing to risk arrest. As the area cleared, police arrested several protesters and escorted them out of the building.

Two Republican senators, Rand Paul of Kentucky and Susan Collins of Maine, have already said they will vote against the bill, meaning Senate Majority Leader Mitch McConnell (R-Ky.) can only lose the support of one more GOP senator and still pass the legislation.

Keeping that in mind, protesters specifically put pressure on Sen. Dean Heller (R-Nev.), who previously said he couldnā€™t support the bill due to its Medicaid cuts. Several demonstrators staged a sit-in in the lobby of his office.

Meanwhile, down the street in Upper Senate Park, protesters staged a ā€œPeopleā€™s Filibusterā€ in a light drizzle to protest the same health care bill.

The bill, which was expected to go to a vote in the Senate this week, has been put on hold while Sen. John McCain (R-Ariz.) recovers from surgery. Activist communities see the delay as an opportunity to ā€œdial up the pressureā€ on lawmakers to oppose the bill, as the event page for the Peopleā€™s Filibuster reads.

ā€œWeā€™re fighting for health care for all Americans,ā€ Marvell Terry II from the Human Rights Campaign told HuffPost. ā€œAnd as a person living with HIV, I know firsthand how much health care improves my daily health, and how people like me, with HIV or other chronic illnesses, need adequate health care and access to good health care.ā€

Terry spoke at the rally, as did Sen. Mazie Hirono (D-Hawaii) and representatives from organizations such as VoteVets and Common Defense.

Stephanie Damassa, a D.C. local, came to the rally with her young baby.

ā€œI just feel like itā€™s so un-American, and itā€™s breaking my heart seeing disabled children that are having to come to the Hill every day to lobby Congress,ā€ she said. ā€œAs an American, I think itā€™s sort of our duty to be here. I just had a child myself, and got my insurance bill for $21,000. Without insurance, I couldnā€™t have afforded that, and to think about all the families throughout our country that are suffering. Our first job should be to protect the vulnerable, and this bill is for the wealthy only, and I just think thatā€™s fundamentally un-American.ā€

Mondayā€™s demonstrations come in the wake of a series of protests against the health care bill, including a ā€œhuman chainā€ march around the Capitol, protests featuring women dressed as handmaids and nationwide sit-ins in senatorsā€™ offices that culminated in several arrests.

http://www.huffingtonpost.com…